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Practice Management Guideline for “Pulmonary Contusion - Flail Chest”
June 2006
EAST Practice Management Workgroup for
Pulmonary Contusion- Flail Chest
Bruce Simon, MD
James Ebert, MD
Faran Bokhari, MD
Jeanette Capella, MD
Timothy Emhoff, MD
Thomas Hayward III, MD
Aurelio Rodriguez, MD
Lou Smith, MD
© Copyright 2006 – Eastern Association for the Surgery of Trauma
PRACTICE MANAGEMENT GUIDELINE FOR THE TREATMENT OF PULMONARY
CONTUSION / FLAIL CHEST:
AN EVIDENCE BASED REVIEW
I STATEMENT OF PROBLEM
Thoracic injury and the ensuing complications are responsible for as much as 25
percent of blunt trauma mortality. 1 Pulmonary contusion in turn is the most common
injury identified in the setting of blunt thoracic trauma, occurring in 30 to 75 per cent of all
cases
2-3
Isolated pulmonary contusion may occur consequent to explosion injury, but
most multi-trauma patients have concurrent injury to the chest wall.4 Conversely, flail
chest, the most severe form of blunt chest wall injury with mortality rates of 10 to 20%,
is typically accompanied by significant pulmonary contusion. 5-9 While injuries to the
chest wall itself may rarely be the primary cause of death in multi-trauma patients, they
greatly impact management and the eventual survival of these individuals. 10 In some
series, most of the severe lung contusions that require ventilatory support (85%) are
associated with severe bony chest wall injury. 10
Despite the prevalence and recognized association of pulmonary contusion and flail
chest (PC-FC) as a combined, complex injury pattern with inter-related pathophysiology,
the mortality and short-term morbidity of this entity has not improved over the last three
decades. 12 Advances in diagnostic imaging and critical care have also failed to impact
upon outcome.12 Additionally, there may be significant long term morbidity associated
with both pulmonary contusion 13 and flail chest, the true extent of which remains
© Copyright 2006 – Eastern Association for the Surgery of Trauma
unclear. 14 This injury constellation particularly affects the elderly who constitute
approximately 10% of the cases but consume 30% of the clinical resources.11
The unchanging mortality and morbidity of pulmonary contusion / flail chest has been
attributed to a misunderstanding of the associated pathophysiology and a lack of
scientifically proven successful management guidelines.12 Consequently, significant
controversy and a wide range of management philosophy exists particularly as relates
to fluid management and ventilatory support.7,9, 15-32
II QUESTIONS TO BE ADDRESSED
This evidence based review will identify the extent and quality of scientific support for
management decisions in regard to the following questions:
1.
What are the appropriate principles for fluid management for patients with
pulmonary contusions.?
2.
Ventilatory support
a.
When is mechanical ventilation indicated for FC-PC?
b.
Is there are role for non-invasive ventilation?
c.
What is the optimal mode of ventilation for severe pulmonary
contusion and/or flail chest?
3.
Is there a role for surgical fixation of flail chest injuries?
© Copyright 2006 – Eastern Association for the Surgery of Trauma
III PROCESS
A computerized search was conducted of the Medline, Embase, Pubmed and
Cochrane controlled trials databases for North American and European English
language literature for the period from 1966 through June 30, 2005 . The initial search
terms were “pulmonary contusion”, “flail chest”, “rib fractures”. chest injuries”, and
“thoracic injuries”. This search initially yielded 91 articles. An additional 45 works were
obtained from the references of these studies yielding a total of 136 papers. Thirty-eight
of these articles were excluded as being case studies, reviews, letters, or otherwise
irrelevant to the questions being asked. The remaining 98 studies were reviewed,
graded and listed in the evidentiary table.
The practice parameter workgroup for pulmonary contusion / flail chest consisted of
eight trauma surgeons, three of whom were also trained and certified as thoracic
surgeons. All studies were reviewed by two committee members and graded according
to the standards recommended by the EAST Ad Hoc Committee for Guideline
Development.33 Grade I evidence was also sub-graded for quality of design utilizing
the Jahad Validity Scale published in Controlled Clinical Trials in 1996.34 Any studies
with conflicting grading were reviewed by the committee chairperson as were all Grade I
studies. Recommendations were formulated based on a committee consensus
regarding the preponderance and quality of evidence.
© Copyright 2006 – Eastern Association for the Surgery of Trauma
IV Recommendations
Level 1
There is no support for Level I recommendations regarding PC-FC.
Level II
1. Trauma patients with PC-FC should not be excessively fluid restricted, but rather
should be resuscitated as necessary with isotonic crystalloid or colloid solution to
maintain signs of adequate tissue perfusion. Once adequately resuscitated,
unnecessary fluid administration should be meticulously avoided. A pulmonary artery
catheter may be useful to avoid fluid overload.
2. Obligatory mechanical ventilation should be avoided.
3. The use of optimal analgesia and aggressive chest physiotherapy should be applied
to minimize the likelihood of respiratory failure and ensuing ventilatory support.
Epidural catheter is the preferred mode of analgesia delivery in severe flail chest
injury. ( see EAST PMG “Analgesia in Blunt Thoracic Trauma)
4. Patients with PC-FC requiring mechanical ventilation should be supported in a
manner based on institutional and physician preference and separated from the
ventilator at the earliest possible time. PEEP / CPAP should be included in the
ventilatory regimen.
5. Steroids should not be used in the therapy of pulmonary contusion.
Level III
1. A trial of mask CPAP should be considered in alert, compliant patients with marginal
respiratory status
2. Independent lung ventilation may be considered in severe unilateral pulmonary
contusion when shunt cannot be otherwise corrected due to mal-distribution of
ventilation or when crossover bleeding is problematic.
3. Diuretics may be used in the setting of hydrostatic fluid overload as evidenced by
elevated pulmonary capillary wedge pressures in hemodynamically stable patients or
in the setting of known concurrent congestive heart failure.
4. Surgical fixation may be considered in severe unilateral flail chest or in patients
requiring mechanical ventilation when thoracotomy is otherwise required.
© Copyright 2006 – Eastern Association for the Surgery of Trauma
V SCIENTIFIC FOUNDATION
Historical Background
Prior to the twentieth century, the entity of pulmonary contusion had rarely been
described and its clinical significance was not recognized. During World War One,
signficant numbers of battlefield dead were noted to be without external signs of trauma
and postmortem studies revealed lung hemorrhage. 35,36,37 Subsequently, the critical
study during this conflict identified pulmonary contusion as the major clinically
significant effect of concussive force.38 This concept was confirmed during the second
world war by studies of animals placed at varying distances from explosive charges.39-42
It was also first noted in military studies at that time that the contused lung produces
more than its normal amount of interstitial and intra-alveolar fluid. 43 Aggressive fluid
resuscitation was cited as a key factor in precipitating respiratory failure after blunt
thoracic trauma.44 Further studies during the Vietnam war laid the basis for the current
philosophies in treatment of pulmonary contusion.45-47 In a study of combined
pulmonary and chest wall injury Reid and Baird 48 were the first to propose that
parenchymal contusion rather than bony thoracic injury was the main factor in
respiratory compromise.
Similarly , until the 1960s , the paradoxical movement of the flail chest component was
believed to be the cause of respiratory compromise in blunt chest wall trauma. 49,50 It
was presumed that this “Pendelluft” caused deoxygenated air to shunt back and forth to
the healthy lung, rather than being exhaled, resulting in hypoxia. Consequently,
treatment was aimed at correcting the paradoxical movement through a variety of
© Copyright 2006 – Eastern Association for the Surgery of Trauma
methods including external fixation 51 and internal fixation by either surgical repair 52 or
positive pressure ventilation.23,53 It was not uncommon to electively maintain patients on
ventilatory support until bony union had occurred.53 It is currently believed that the
underlying lung contusion is a major cause of respiratory compromise with the bony
chest wall injury creating the secondary problems of pain and splinting. 48 Contemporary
practice has therefore been directed at addressing these issues. 8,22,54
Pathophysiology
The local pathophysiology of injured lung was first delineated by animal studies in the
1970’s. Oppenheimer 55 studied clinical behavior and pathologic findings in class I study
of contused dog lung. He identified contusions as lacerations to lung tissue which leaked
blood and plasma into alveoli . He noted reduced compliance resulting in reduced
ventilation per unit volume and increased shunt fraction. Other studies identified
thickened alveolar septa in contused lung with consequent impaired diffusion. 56 Fulton
defined the significant and progressive decrease in pO2 values in contused dog lung
over a 24 hour period.57 An increase in pulmonary vascular resistance and consequent
decrease in blood flow was noted in the contused lung. In other studies, these changes
were not altered by the concurrence of flail chest injury.58 In a small observational study
of blunt trauma patients, Wagner also noted increases in pulmonary vascular resistance
in proportion to contused volume and felt this acted as a compensatory mechanism to
minimize shunt fraction.59
The effects of contusion on uninjured lung have also been recently elucidated through
animal studies. Davis performed an elegant class 1 study of a porcine model of blunt
© Copyright 2006 – Eastern Association for the Surgery of Trauma
chest trauma.60 Unilateral chest trauma produced an early rise in bronchoalveolar
lavage (BAL) protein on the injured side as well as a delayed capillary leak in the
contralateral lung. Similarly, Hellinger showed that uninjured lung, both ipsilateral and
contralateral developed thickened septa, increased vacuolation and edema over an eight
hour post-injury period.56 Though this occurred to a lesser extent than in injured lung, the
findings were statistically significant compared to controls (p<.01) Also, in this study,
BAL showed an increase in neutrophils (PMNs) in contused lung, and ipsilateral and
contralateral uninjured lung compared to controls. Local and systemic complement
levels (TCC = terminal complement complex) increased and C3 complement decreased
to a statistically significant level.
Consequently, high grade evidence from animal studies indicated that pulmonary
contusion is not merely a localized process , but probably has global pulmonary and
systemic effects when occurring in a sufficient portion of the lung. Table 1 summarizes
the reported physiologic effects of lung contusion. Reviewed literature is graded and
summarized in the evidentiary tables.
© Copyright 2006 – Eastern Association for the Surgery of Trauma
Local Effects
Laceration to lung tissue
Hemorrhage-filled alveoli
Reduced compliance yielding reduced ventilation
Increased shunt fraction with decrease in pO2, increase in AaDO2
Increased pulmonary vascular resistance
Decreased pulmonary blood flow
Injured and Uninjured Lung (Ipsilateral and Contralateral)
Thickened alveolar septa with impaired diffusion
Decreased alveolar diameter
Vacuolation of pulmonary tissue
Delayed capillary leak with increased BAL protein
Increased neutrophils in lung tissue
Systemic
Increased TCC
Decreased complement
Table 1 Reported physiologic Effects of Lung Contusion
PO2 = partial pressure of oxygen
AaDO2 = alveolar-arterial oxygen difference.
BAL = bronchoalveolar lavage
TCC = terminal complement component
© Copyright 2006 – Eastern Association for the Surgery of Trauma
Outcome
Numerous studies have addressed the outcome of pulmonary contusion / flail chest
injury (PC/FC) but have had difficulty in separating the effects of the chest wall and
parenchymal components.5,10,13-14,19,61-68 In terms of mortality, it remains controversial
whether this constellation of thoracic injury is a direct cause of death 63 or merely a
contributor in the setting of multi-trauma.5,61,64 In separate reviews, Clark and Stellin
both noted that central nervous system trauma was the most common associated
injury. Few deaths in these retrospective studies ( n=144; n=203 ) were due to
pulmonary failure per se, but rather to brain injury and shock. While Rellihan agreed
that associated brain injury was the most common cause of death in flail chest patients,
his review (class III n=85) indicated that complications of the pulmonary injury were
contributory at least half the time.64 Conversely, Kollmorgen, in a retrospective review of
100 trauma deaths among patients with pulmonary contusion felt that 70% of the
deaths were due to the lung injury or pulmonary failure primarily.63
In terms of morbidity, the long-term outcome of flail chest injury was first addressed in
the 1980’s by several workers 14,66 In a retrospective review, Landercasper noted that
46% (n=32) of flail chest patients did not have normal chest wall expansion, 24% had
obstructive changes on spirometry and 20% had restrictive changes.66 Vital capacity
was normal in only 57% 70% had long term dyspnea and 49% had persistent chest
wall pain. The possible contribution of pulmonary contusion was not addressed and CT
scanning was not done at this time. Similarly, Beal reviewed 20 patients with flail chest
and a variety of associated thoracic injuries from 50 to 730 days and also noted that the
most common long-term problems were persistent chest wall pain, chest wall deformity
and exertional dyspnea.14 The etiology of the respiratory symptoms was not identified.
© Copyright 2006 – Eastern Association for the Surgery of Trauma
In the 1990’s, attempts were made to determine whether the flail chest, pulmonary
contusion or both components were responsible for the long-term disability which is
seen with the more severe injuries.
13-14,66,69
In a small (n=18), but well-validated, blinded
Class I study, Kishikawa followed the pulmonary functions and radiographic findings of
PC-FC patients for 6 months.13 His group was trying to explain the persistent dyspnea
often seen after blunt chest trauma. They noted that pulmonary function recovered
within 6 months in patients without pulmonary contusion, even in the presence of severe
residual chest wall deformity. However patients with pulmonary contusion had
decreased functional residual capacity (FRC) and decreased supine paO2 for years
afterward. Figure 1, from Kishikawa’s work shows the course of FRC in patients with
pulmonary contusion with or without flail chest and with flail chest alone.
Figure 1. The course of functional residual capacity over 6 months in patients with pulmonary
contusion alone (solid circle / dashed line) , pulmonary contusion with flail chest (solid circle / solid
line), flail chest without pulmonary contusion ( open circle / solid line), and trauma controls with
neither injury (open circle / dashed line). From Kishikawa M, Yoskioka T: Pulmonary cotusion cause
long-term respiratory dysfunction with decreased functional residual capacity. J Trauma
1991;32:1203-8.
In further work by Kishikawa, 58% (n=14/24) of contused lungs showed fibrosis on CT
scan 1 to 6 years post-injury.69 The average spirometry for patients with contused
lungs was 76% of normal vs 98% of normal for controls. Air volume measured by CT
© Copyright 2006 – Eastern Association for the Surgery of Trauma
scan supported these findings. From these studies, it was concluded that the flail chest
component causes short term respiratory dysfunction while the pulmonary contusions
are responsible for the long term dyspnea, low FRC and pO2. The main cause of the
persistent decreased air volume was felt not to be the residual thoracic deformity but
rather the loss of pulmonary parenchyma by fibrosis of the contused lung. Studies
addressing the outcome of PC-FC are tabulated in the evidentiary tables.
Fluid Management
Present practice regarding type of quanitity of fluid resuscitation for multi-trauma patients
with concurrent pulmonary contusion has been largely extrapolated from animal
research or retrospective studies.15-20 As early as 1973, Trinkle studied experimental
right lower lobe pulmonary contusions and noted that crystalloid resuscitation caused
the lesions to be larger than did colloid use.16 Concurrent diuresis caused all lesions to
decrease in size. However, when lesion size was corrected for lobe weight to body
weight index, these results were not statistically significant. Also in the 70’s , Fulton
studied a dog model of pulmonary contusion and noted that fluid resuscitation increased
the percentage of water in the contused lung over control groups resulting in
“congestive atelectasis”. This effect was unchanged whether or not the animals were
allowed to hemorrhage to shock prior to volume replacement or gradually resuscitated.
Similarly, Richardson performed a well-designed randomized blinded (class I) study of
canine pulmonary contusion (n=34).17 He noted that animals receiving lactated ringers at
various doses had declining oxygenation levels (pO2) and increased lung water when
compared to those receiving plasma. (p<.05) The authors concluded that colloid was
superior to crystalloid for resuscitation in the setting of pulmonary contusion. However,
© Copyright 2006 – Eastern Association for the Surgery of Trauma
in a single limb study of109 human patients with PC, Bongard 18 could not find a
correlation between plasma oncotic pressure and oxygenation as determined by the
PaO2/FiO2 ratio. He concluded that pulmonary dysfunction after contuson is unrelated
to hemodilution by crystalloid. Finally, Richardson retrospectively reviewed 86 patients
with PC and found that mortality correlated with admission pulmonary function
(PaO2/FiO2 <300 ; p<.05) but not with the amount of intravenous fluid administered.17
Decision for Ventilatory Support
As early as 1973, Trinkle showed that early intubation and application of positive end
expiratory pressure (PEEP) decreased the size of experimental pulmonary contusion vs.
controls. 16 Similarly, workers such as Shin provided some class III evidence that
progressive pulmonary deterioration in humans was lessened by immediate intubation
and ventilation for every lung contusion.70 Consequently, the de facto standard at that
time for treatment of PC was obligatory mechanical ventilation. Yet, there was no
credible data showing improved survival with this approach. 9
Similarly, in the 1970’s it was felt that some form of stabilization of the mobile chest
wall was the critical treatment for the flail chest component and that mechanical
ventilation for “internal pneumatic stabilization” was the optimal way to achieve this
regardless of the patient’s pulmonary function.23,53 Evidence supporting this was mostly
observational (Class II). 23,53 Workers such as Christensson felt that mandatory
tracheostomy and two to three weeks of positive pressure ventilation would allow the
chest wall to stabilize in a “favorable position”.23 Follow-up studies showed return of
normal mechanics but non-ventilated control groups were not utilized.
© Copyright 2006 – Eastern Association for the Surgery of Trauma
Trinkle was the first to raise the possibility that obligatory mechanical ventilation for flail
chest was not necessary.9 In a small (n=30) retrospective review with well-matched
cohorts, the obligatory ventilation group had a longer hospital stay (22.6 days vs. 9.3
days, p<.005), a higher mortality ( 21% vs. 0% p<.01) and a higher complication rate (
23 vs 2 p<.01) than the selective group. The “selective” group averaged only .6 ventilator
days, indicating that the conservative management was often successful. Similarly,
Richardson studied 135 patients with isolated PC and 292 patients with PC-FC.8
Intubation was successfully avoided in 80% of patients with PC and 50% of patients
with PC-FC. This study did not employ matched cohorts and the intubated patients
were selected by failure of selective management. But the study did demonstrate that
the majority of patients could be successfully managed without ventilatory support.
In a landmark work, Shackford and colleagues carried out a well-constructed case
control study (Class II) of selective ventilatory support with the endpoints of treatment
being normalization of oxygenation, shunt and alveolar-arterial oxygen gradient.22 Their
study demonstrated worse survival in the ventilated group due to the complications of
mechanical ventilation. Shackford’s group concluded that mechanical ventilation should
be used to correct abnormalities of gas exchange rather than to overcome instability of
the chest wall.
In a prospective study several years later, Shackford’s group divided
FC patients (n=36) by severity of injury and provided ventilatory support only when a
clinical indication developed.25 Outcomes were compared to historical controls. Overall
ventilatory rates decreased from 74% to 38% (p<.01) from the prior study and mortality
from 14% to 8%. (p<.01) Other recent studies have supported the selective use of
ventilatory support for defects of gas exchange and clinical indications only, rather than
© Copyright 2006 – Eastern Association for the Surgery of Trauma
for correction of mechanical abnormalities of the chest wall.7,24,26 Studies addressing
decision for ventilatory support are reviewed and graded in the evidentiary tables.
Modes of Ventilatory Support
As early as 1972 Trinkle clearly demonstrated that the size of experimental pulmonary
conrtusions in dogs was significantly decreased by the applications of PEEP.16 The
initial prospective human study by Sladen involved varying levels of PEEP in a small
group of patients (n=9) who served as their own controls.21 Despite the small study size,
pO2 improved to a significant degree in all patients with PEEP of 10 or 15 cm of water.
There was no change in physiologic dead space and therefore the improvements were
attributed to alveolar “recruitment” or increased functional residual capacity (FRC). Rib
fracture alignment was anecdotally noted to be improved on fluoroscopy but the
significance of this was not addressed. Survival benefit could not be assessed as this
was a single arm study.
Only occasional work has addressed the actual choice of ventilatory modes for PC-FC
injuries. In the salient work on this issue, Pinella studied the use of Intermittent
Mandatory Ventilation (IMV) in 144 patients with varying severity of flail chest against
historical controls on Continuous Mandatory Ventilation (CMV).27 Groups were well
matched in terms of severity of flail and associated injuries. No difference could be
identified in terms of duration of ventilatory support, level of PEEP or FiO2 or outcome
between the CMV and IMV group.
© Copyright 2006 – Eastern Association for the Surgery of Trauma
Recent attention has focused on the use of continuous positive airway pressures modes
(CPAP) both non-invasively and by endotracheal intubation.30,32 The critical animal study
by Schweiger compared IMV to CPAP in three groups of pigs: a control group, FC
group and PC-FC group.32 Ten to 15 cm of CPAP was beneficial over IMV alone for
correcting alveolar closure thereby minimizing shunt fraction (p<.001) and improving
compliance significantly (p<.006) The need for IMV was signficantly reduced after the
application of CPAP in all animals. (p<.01) This effect was more pronounced in PC-FC
than in isolated flail chest. (p<.01)
Similarly, in humans, Tanaka prospectively studied
the use of non-invasive CPAP in 59 patients with FC injury. (Class II) Study patients
were compared to historical controls treated for respiratory failure prmarily with
mechanical ventilation.30 Groups were well matched in terms of extent of chest wall
injury and overall injury severity. The CPAP group had a lower rate of pulmonary
complications (atelectasis 47% vs 95%; pneumonia 27% vs 70%; p<.01). and a
significantly lower rate of mechanical ventilation. Recently, Gunduz executed a welldesigned randomized comparison of mask CPAP to intermittent positive pressure
ventilation via endotracheal intubation (n=52). 71 CPAP led to a lower mortality (20%,
5/25 vs 33% 7/21 p<.01) and nosocomial infection rate (4/22, 18% vs. 10/21, 48%
p=.001) Mean pO2 was higher in the ET group initially ( 2 days p<.05) but then
equalized. A difference in the length of ICU stay could not be demonstrated.
Independent lung ventilation ( ILV) has also been employed sporadically over the last
20 years.72-82 This modality has been applied to patients with severe unilateral chest
trauma, predominantly pulmonary contusion in whom major ventilation-perfusion (V/Q)
mismatch has been unresponsive to conventional support. Most of the work on this
modality has consisted of case reports 72-79 or small, uncontrolled, single-limb
observational studies 80-82 which report improved oxygenation and survival in patients
© Copyright 2006 – Eastern Association for the Surgery of Trauma
who were failing conventional ventilation. The rationale for ILV rests with the supposition
that the severe V/Q mismatch of extensive pulmonary contusion is worsened by the
asymmetrical compliance of the injured lung.72 This occurs through diversion of
ventilation to more compliant areas causing over-distention of normal alveoli. Hurst and
colleagues initiated ILV for eight patients with unilateral pulmonary contusion with and
without flail chest who were failing conventional support.82 Significant improvements
were obtained in PaO2 ( 72+8.7 to 153+37; p<.005) and shunt fraction (28+3.5 to
12.6+2.5; p<.005) No significant changes occurred in cardiac output, peripheral
resistance or oxygen extraction index. Seven of the eight patients survived. Though this
study was prospective, selection was non-random and no control group was studied.
(class II) Studies addressing modes of ventilatory support are reviewed and graded in
the evidentiary tables.
Finally, the successful use of high frequency jet ventilation has anecdotally been
reported in pulmonary contusion.83 However the indication and effectiveness has not
been formally investigated.
Surgical Repair of Flail Chest
Surgical stabilization of flail chest injury has been employed with some frequency in
Europe and Asia from the 1950’s until present day.84-89 Relatively little experience has
been accrued recently in the United States.90 The surgery involves a significant
operative procedure with mobilization of large chest wall flaps or open thoracotomy.84
(see figure 2) A variety of devices are then employed to stabilize the fracture fragments
including medullary wires or nails, Judet struts or compression plates. 84,86-87,89-91 (see
© Copyright 2006 – Eastern Association for the Surgery of Trauma
figure 3) Specifics of the operative technique are beyond the scope of this review and
the reader is referred to specific reports on the subject.84,86-87,89-91
Figure 2. Incisions for internal fixation of flail chest injuries. From Moore BP. Operative
Stabilization of Non-penetrating Chest Injuries. J. Thorac. Cardiovasc. Surg. 1975;
70:619-630.
Figure 3. Internal fixation of rib fracture by intramedullary nailing. From Moore BP.
Operative Stabilization of Non-penetrating Chest Injuries. J. Thorac. Cardiovasc. Surg.
1975; 70:619-630.
© Copyright 2006 – Eastern Association for the Surgery of Trauma
Numerous European studies report “good” results with surgical fixation of FC, citing
decreased pain, improved mechanics compared with pre-operative performance, “rapid”
separation from mechanical ventilation and excellent return-to-work outcomes. Yet
these studies are mostly small, single-limb, observational studies of personal
experience lacking non-surgical controls. (classes II and III)
56,84-85,87,90-94
In some, patient
selection is non-random.88-89,91,93-96 Consequently, though surgical fixation clearly
corrects the anatomic chest deformity, comparison of efficacy to conservative treatment
is problematic.88
Tanaka and associates performed the salient randomized, controlled study (class I) of
operative fixation vs. internal pneumatic stabilization.97 Groups (n=37) were well
matched in terms of injury severity, criteria for ventilatory support and ventilator
management. The incidence of pneumonia was less in the surgical group (22% vs 90%)
as was the length of ventilation and length of ICU stay. The investigators reported
improved lung volumes, decreased pain and dyspnea and higher return-to-work at one
year with surgical fixation. All findings were significant to p<.05. Tanaka’s group
concluded that surgical stabilization may be preferable for severe flail chest patients
when prolonged ventilatory support would otherwise be expected. In a similar, but
retrospective review of 64 patients, Balci also compared operative fixation to ventilator
support.96 The surgical group had a lower mortality (11% vs 21%), less ventilator days (
3 vs 6.6) and less narcotic use. However, patient allocation was not randomized in this
study. Finally, Voggenreiter compared the outcome of operative fixation for flail chest
alone and flail with pulmonary contusion to a non-operative control group.98 Groups
were well matched. “Pure” FC patients benefited from surgical fixation in terms of
separation from mechanical ventilation ( 6.5 vs 30 days; p<.02) while those with FC-
© Copyright 2006 – Eastern Association for the Surgery of Trauma
PC did not ( 27 vs. 30 days). These authors concluded that FC and respiratory
insufficiency without underlying pulmonary contusion is an indication for surgical fixation.
They felt that the presence of FC-PC precludes benefit from primary fixation but that
secondary stabilization may be indicated in the weaning period. This study was
uncontrolled, retrospective and involved a small sample size. No prospective,
randomized controlled studies are identified comparing surgical fixation to modern
conservative treatment with epidural analgesia and chest physiotherapy. Available
literature addressing surgical fixation of flail chest is reviewed and graded in the
evidentiary table.
Other Therapies
The use of steroids for the treatment of pulmonary contusion has rarely been addressed
in the literature. Franz administered methylprednisolone 30 minutes after creation of
experimental pulmonary contusion in dogs.99 The weight ratio of contused to normal
lung was significantly decreased in treated animals and the volume of injury was less on
postmortem (p<.05). Since the animals were sacrificed, the effect of steroids on
recovery and survival could not be assessed.
In a small retrospective human study,
Svennevig concluded that the mortality in severe chest injury was reduced through the
use of steroids.100 This study however, involved neither randomization nor constant
criteria for administration of steroids. Since the cause of deaths were not specified, it
was difficult to assess the complications and risk vs. benefit of steroid use.
© Copyright 2006 – Eastern Association for the Surgery of Trauma
VI CONCLUSION
Pulmonary contusion / flail chest is a common injury constellation in blunt trauma. While
injuries to the chest wall itself may rarely be the primary cause of death in multi-trauma
patients, they greatly impact management, survival, and long-term disability. When
occurring in sufficient volume of the lung, pulmonary contusion may have adverse global
pulmonary and systemic effects.
Most of the current practice in treatment of PC-FC derives from a modest quantity of
Class II and III work , extrapolation of animal research and “local custom”. There is
currently no credible human evidence that “fluid restriction“ improves outcome though it
has been shown to improve oxygenation in animal models. Respiratory dysfunction after
contusion may ultimately be shown to relate more to direct traumatic and indirect
biochemical effects of the injury rather than amounts of fluid administered. In terms of
ventilatory management, the bulk of current evidence favors selective use of mechanical
ventilation with analgesia and chest physiotherapy being the preferred initial strategy.
When support is required, no specific mode has been shown to be superior to others
though there is reasonable evidence that addition of PEEP or CPAP is helpful in
improving oxygenation. While the literature supporting the use of independent lung
ventilation in severe unilateral. pulmonary contusion is largely observational, the majority
of work supports the opinion that it may be beneficial in select patients. Finally, surgical
fixation of flail chest has not been credibly compared to modern selective management,
but may also be a valuable addition to the armamentarium in appropriate circumstances.
© Copyright 2006 – Eastern Association for the Surgery of Trauma
VII AREAS FOR FURTHER INVESTIGATION
Significant quantitative and qualitative gaps exist in the body of knowledge regarding
PC-FC. Areas in need of further investigation include:
1. Effect of hypertonic saline resuscitation on PC
2. Anti-inflammatory “anti-cytokine” Rx
3. Modes of ventilatory support
4. Non-invasive ventilatory support
5. Surgical fixation
6. Long-term outcomes
© Copyright 2006 – Eastern Association for the Surgery of Trauma
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© Copyright 2006 – Eastern Association for the Surgery of Trauma
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© Copyright 2006 – Eastern Association for the Surgery of Trauma
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© Copyright 2006 – Eastern Association for the Surgery of Trauma
First Author
Reference
Data
Clas
s
Conclusions of Study / Comments
MANAGEMENT OF PULMONARY CONTUSION / FLAIL CHEST: A LITERATURE REVIEW
Year
Historical Background
The Management of 220 Cases of
Flail Chest Injuries. J. Surg. S.
Afr. 1977; 15:21-30
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Sealy
1946 Sealy WC: Contusions of the lung
from non-penetrating injuries to
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the thorax. Arch Surg 1949; 59:
882-7
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1982 Taylor GA, Miller HA, et al:
Symposium on Trauma:
2
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of Pulmonary Contusions. Can J
Surg. 1982; 25:167-170
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1996 Allen GS, Coates NE: Pulmonary
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Am Surg 1996; 62:895-900
Cohn
1997 Cohn SM: Pulmonary Contusion:
Review of the Clinical Entity. J
Trauma 1997; 42:973-9
4
Flail Chest (9)
Wilkinson 1977
5
© Copyright 2006 – Eastern Association for the Surgery of Trauma
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Shorr
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Brotzu
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Landercas
per
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Mangete
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1994
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M: Blunt Thoracic Trauma:
Analysis of 515 Patients. Ann
Surg 1987; 206:201-5
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al: Chest Injuries: A Review of
195 patients. Ann Chir et Gyn
1988; 77:158-9
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PJ: Delayed Diagnosis of Flail
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Igbaseimokumo U, et al: Modern
Concepts in the Mangement of
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Ciraulo DL, Elliott D, Mitchell KA,
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A comprehensive analysis of
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mortality and management. Eur.
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© Copyright 2006 – Eastern Association for the Surgery of Trauma
Pathophysiology
1976
Blair EB: Pulmonary Barriers to
Oxygen Transport in Chest
Trauma. AM Surgeon.
1976;__:55-61
II
An
3
2
AN
1979
Pulmonary Contusion / Flail Chest (12)
Fulton
1970 Fulton RL, Peter ET: The
progressive Nature of Pulmonary
14
Contusion. Surgery 1970; 67:499506
Blair
15
Craven
16
Craven KD, Oppenheimer L:
Effects of contusion and flail chest
on pulmonary perfusion and
oxygen exchange. J Applied Phys
1979;47:729-37
A prospective controlled experimental animal design without
randomization or blinding – 6 dogs There is a significant and
progressive decrease in pO2 values in the experimentally contused
dog lung over a 1-24 hour period. There is an increase in PVR and a
decreased flow in the contused lung. A short trial of high
concentration, moderate positive pressure ventilation did not improve
the oxygen diffusion barrier. Histologic examination of the lung
revealed edema and cellular infiltration of the tissue over this same
time period.
Retrospective cohort series. 75 % of both flail and flail/contusion
patients demonstrated hypoxia day one without differentiating
physiologic characteristics (A-aDO2) at that time. Beginning day 3,
the A-aDO2 differentiated the two groups with values of 300 mm Hg
or higher indicating flail chest accompanied by contusion. In
flail/contusion, the A-aDO2 reached values up to 600 mm Hg. The
elevation in A-aDO2 separated the two groups until day 5 when these
values began to decline in the presence of contusion. No significant
difference in A-aDO2 remained at day 8.Conclusion: Blood gas
analysis and the estimation of the A-aDO2 differentiate between flail
chest alone and flail chest accompanied by lung contusion. A-aDO2
increases indicating pulmonary contusion precede morphological
findings of the same on CXR. Declining A-aDO2 values are superior
to CXR in following the improvement of pulmonary contusion. A spike
in the A-aDO2 will indicate complications such as pneumonitis before
identification on CXR. A-aDO2 values assist in patient management
concerning ventilator support, fluid restriction, diuretic and
corticosteroid usage. No statistical validation provided.
Cohort study of 24 dogs Sig. Decrease in PaO2 and RLL perfusion
as well as increase in lobe weight with contusion. Not altered by
concurrence of flail chest. Decreased perfusion of RLL limited shunt.
© Copyright 2006 – Eastern Association for the Surgery of Trauma
Oppenhei
mer
17
Richardso
n
18
Tranbaug
h
19
1982
1979
1979
Tranbaugh RF, Elings VB:
Determinants of pulmonary
interstitial fluid accumulation after
trauma. J Trauma 1982; 22:820-6
Richardson JD, Woods D: Lung
bacterial clearance following
pulmonary contusion. Surgery
1979; 86:730-5
Oppenheimer L, Craven KD:
Pathophysiology of pulmonary
contusion in dogs. J Applied Phy
1979;47:718-728
3
2
AN
I
AN
Prospective controlled, randomized laboratory study of 25 doegs with
experimental pulmonary contusion. Pulmonary contusion leaks blood
and plasma into air spaces of the lung, reducing its compliance and
resulting in a reduced ventilation per unit of volume and increased
shunt fraction both locally in the lobe and to a lesser extent overall.
Lungs ventilated wih PEEP had a higher weight than those
notventilated with PEEP. PEEP increased oxygenation, but worsened
contusion.
A prospective randomized non –blinded animal cohort study of 16
dogs. Aerosolized bacteria introduced into four groups 1-contusion
alone; 2-contusion + fluid loading; 3 – contusion +systemic
hemorrhage; 4- contusion + steroids. Stat analysis: none.
Conclusions: Contusion itself does not alter bacterial lung clearance .
Clearance was lowered with contusion + fluid load, contusion +
systemic hemorrhage and with steroids.
Study of 16 patients with alleged severe lung injury, but no definition
of criteria for same. No standardization of terms or therapies.
Generalized conclusion OK: interstitial lung water increases with
membrane injury from any cause
© Copyright 2006 – Eastern Association for the Surgery of Trauma
Wagner
20
Hellinger
21
Aufmkolk
22
1996
1995
1991
Aufmkolk M, Fischer R,
Kleinschmidt C, et al: Effect of
Lung Contusion on Surfactant
Composition in Multiple Trauma
Hellinger A, Konerding MA: Does
lung contusion affect both the
traumatized and the noninjured
lung parenchyma? A
morphological and morphometric
study in the pig. J Trauma 1995;
39:712-9
Wagner RB, Slivko B: Effect of
lung contusion on pulmonary
hemodynamics. Ann Thorac Surg
1991; 52:51-8
2
2
AN
2
Prospective nonrandomized study of 25 blunt trauma pts with
pulmonary contusion. There are 3 different subpopulations of
patients: the reactors (5pts), the weak reactors (10pts) and the nonreactors (10pts). This refers to pulmonary vasoconstriction per unit of
lung injury (PVRI/ASF). Rank correlation coefficient was used.
The PVRI increases with size of contusion (ASF) more strongly in
reactors than in the non-reactors.
The shunt fraction remains below 0.31 in both the reactor groups. In
nonreactors the PVRI remained normal while the shunt fraction
increased with extent of injury.
Conclusion: Pul vasoconstriction minimizes shunt fraction in lung
injury in reactors.
Criticism: Non-randomized trial, no non-contusion patients as controls
.
Design: Cohort study with 12 pigs. Results: Contused lung has
hemorrhage, thickened septa, and decreased alveolar diameter.
Uninjured lung, both ipsilateral and contralateral, has thickened septa,
increased vacuoles and increased edema. BAL showed increased
PMN's in both contused and contralateral lung compared to controls.
There was increased PVR and mPAP after contusion and decreased
Horovitz quotient, and compliance. The TCC increased and C3
decreased. Statistical methods: Chi squared test for septal
thicknesses and alveolar diameters; p<0.01. Student's t test for
hemodynamic and respiratory parameters; p<0.05. Conclusions:
Increased septal diameter and decreased alveolar diameter occur to
different extents in both contused and contralateral lung.
Measurements of TCC and C3 support presence of systemic
inflammatory response after direct lung injury. Structural changes are
accompanied by worsening hemodynamics and lung mechanics.
Strengths: Very well done. Weakness: Only 8 hour time period. Do
these structural changes reverse with time?
No definition of lung contusion. No recommendations: observations
only: only direct lung injury with organ failure results in changes in
surfactant, however study did not include patients with organ failure
who did not have lung injury.
© Copyright 2006 – Eastern Association for the Surgery of Trauma
Patients. J Trauma. 1996;
41:1023-9
© Copyright 2006 – Eastern Association for the Surgery of Trauma
Cohn
23
Obertacke
24
Davis
25
1996
1998
1999
Cohn SM, Zieg PM: Experimental
pulmonary contusion: Review of
the literature and description of a
new porcine model. J Trauma
1996; 41:565-71
Obertacke U, Neudeck F: Local
and systemic reactions after lung
contusion: An experimental study
in the pig. Shock 1998; 10:7-12
2
AN
N/A
Animal study
Davis KA, Fabian TC:
1
Prostanoids: early mediators in
AN
the secondary injury that develops
after unilateral pulmonary
contusion. J Trauma 1999;
46:824-31
Controlled, randomized, non-blinded animal study of 12 pigs.
Results:
1. Systemic as well as local activation of PMNs, sequestration in
lungs.
2. Surfactant significantly impaired in both lungs; phospholipids not
impaired.
3. Early local and systemic activation of complement
Recommendation: early use of ibuprofren or pentixophyline to protect
contralateral lung.
Justification: well done experimental study. “Opens door” to ue of
drugs that protect contralateral lung.
Design of Study: Cohort study of anesthetized ventilated pigs with
unilateral blunt injury from bolt gun (n=20) versus control sham (n=5).
Injured group was subdivided into no treatment versus administration
of Indomethacin 15 minutes before injury Type: Cohort. Number of
Patients: 25 Animal. Results: Contusion resulted in a significant: rise
in pulmonary artery pressure and hypoxia with decrease in PaO2 to
50% of baseline within 1 hour of injury. Indomethacin group had a
higher PaO2 than no treatment group at every level of PEEP.
Unilateral chest trauma produced an early rise in BAL protein on the
injured side and a delayed capillary leak on the contralateral side.
These changes were reduced by 40-60% with indomethacin.
Thromboxane rise post injury blocked by indomethacin and
Prostacyclin rise delayed by indomethacin for 18 hours. Statistical
Methods / Significance: Analysis of variance and Fisher Exact test
with 95% CI Conclusions / Recommendations of Study: Indomethacin
blocked or attenuated two inflammatory mediators but did not prevent
the progression of pulmonary failure. Jadad Validity Scale for Grade I
Evidence Study described as randomized = 0/1 no but implied
Randomization appropriate=0 Study described as double blinded=0
© Copyright 2006 – Eastern Association for the Surgery of Trauma
Borrelly
26
2005
Borrelly J, Aazami MH: New
insights into the pathophysiology
of the flail segment: implications
of the anterior serratus muscle in
parietal failure. Eur J CT Surg.
2005; 28:742-9
3
Blinding appropriate=0 Description of withdrawals or dropouts=0
Total=0.5 Justification grading: Limited numbers in animal study,
animals always ventilated in controlled environment, treatment group
pretreated prior to injury, frequent use of bilateral BAL, potential for
ventilator induced lung injury from ventilator protocol in study.
N=127.Authors demonstrated via radiographic studies that flail
segments secondarily dislocate through a complex set of actions
involving the serratus anterior and other muscles. They present this
concept as a logical indication for surgical repair of flail segments.
© Copyright 2006 – Eastern Association for the Surgery of Trauma
OUTCOME
Pulmonary Contusion (7)
Johnson
1986 Johnson JA, Cogbill TH:
(*2)
Determinants of Outcome after
Pulmonary Contusion. J Trauma
27
1986; 26:695-7
Clark
1988 Clark GC, Schecter WP:
Variables affecting outcome in
28
blunt chest trauma: Flail chest vs.
pulmonary contusion. J Trauma
1988; 28:298-304
3
Design: Retrospective chart review of 144 patients. Results: Main
outcome variable was mortality. Fifteen percent of those with first and
second rib fractures had an aortic injury. Twenty-eight percent of
those with lower left rib fractures had a splenic injury. Fifty -six
percent of those with lower right rib fractures had a liver injury. CNS
injuries were the most common associated injury and most common
cause of death. Those with flail chest and flail + pulmonary contusion
had higher ISS, and higher morbidity and mortality. Atelectasis and
pneumonia were the most common complications. ARDS was
infrequent. Did not include isolated pneumothorax, hemothorax or rib
fractures. Statistics: Two tailed Student's t test for age, ISS, number
days ventilated, length of stay, days in ICU. Chi square test for
male:female ratio, % ventilated, shock incidence, % associated
thoracic injuries and incidence of complications. P<0.05 Conclusions:
Those with first and second rib fractures should get aortography.
Mortality was associated with shock, high ISS, brain injury, falls from
heights, combination pulmonary contusion and flail, associated aortic
injury. Few deaths were due to pulmonary failure but rather brain
injury and shock. Strength: Main conclusions supported.
Weaknesses: Retrospective. Cannot be sure all appropriate patients
were included. Were there really only 144 patients over five years?
© Copyright 2006 – Eastern Association for the Surgery of Trauma
Kishikawa
29
Stellin
30
Kishikawa
31
1991
1991
Stellin G: Survival in trauma
victims with pulmonary contusion.
Am Surg 1991; 57:780-4
Kishikawa M, Yoskioka T:
Pulmonary contusion causes
long-term respiratory dysfunction
with decreased functional residual
capacity. J Trauma 1991; :12038
1993
Kishikawa M, Minami T, Shimazu
T, et al. Laterality of Air Volume in
Lungs Long After Blunt Chest
Trauma . J Trauma 1993;34:
908-13
1
Jadad
4
3
3
Prospective randomized blinded study measuring PFTS, particularly
FRC in patients with PC and without.
Results” In PC group, FRC remains abnormal > 6 months.
Conclusions: Flail chest component causes short term respiratory
disfunction while PC causes long term dysfunction with dyspnea, low
FRC and PaO2..
Justify grading: well done study with stat support. Conclusions are
supported by study.
Design of Study: Retrospective review from single trauma center over
5 years. All patients had either a pneumothorax or hemothorax or
both. Contusions were defined with radiological evidence of
progression on CXR or CT scan. Isolated rib fractures without
evidence of pulmonary contusion were excluded. Type:
Observational. Number of Patients: 203 Human. Results: Mortality for
contusion 20% but 42% if patient older than 60. Flail chest occurred in
8% of patients with 30% mortality rate. 68% of patients who died had
GCS<7 with 43% brain death. 25% died in ER. 34% of patients (all
survivors) never required intubation. Statistical Methods /
Significance: Chi square analysis of two proportions with Yate’s
correction. P<0.05. Conclusions / Recommendations of Study: Head
injury associated with presence of shock is responsible for high
mortality of chest injuries. Justification grading: Limited numbers and
lack of detailed homogenous subgroups with true isolated pulmonary
contusions prevents quantification of true pulmonary outcomes.
Retrospective review Results: 17 patients with severe blunt chest
trauma and lung contusion were compared with 10 normal volunteers
(control group) to clarify the cause of persistent decreased lung
capacity. Ten patients had unilateral lung contusions, and 7 bilateral
lung contusions. Flail chest was diagnosed in 7 patients with
unilateral lung contusions and in 4 with bilateral lung contusion. CT
scanning was used to measure air volume laterality in contused lung
and compared reliably with spirometry measurements. 14 of 24
(58%) contused lungs showed fibrosis on CT scan 1 to 6 years
following blunt chest trauma. The average air volume spirometry in
© Copyright 2006 – Eastern Association for the Surgery of Trauma
Hoff
32
1994
Hoff SJ, Shotts ST: Outcome of
isolated pulmonary contusion in
blunt trauma patients. Am Surg
1994; 60:139-41
3
patients with contused lungs was (76% +/- 8%) compared with the
controls (98% +/-5%). The average air volume measured by CT
(71% +/-8%).:: Paired or unpaired Student’s t test. Probabilities less
than 5% (p<0.05) were considered significant. Conclusions: The main
cause of decreased AV (air volume) is not thoracic deformity
remaining after flail chest, but loss of pulmonary parenchyma from the
constriction of fibrosis. Lung AV is decreased in patients with lung
contusion long after blunt chest trauma; air volume of unilaterally
injured lungs is severely reduced on the contused side, CT scans
show fibrosis changes in contused lung long after the injury,
persistent decreased AV long after lung contusion seems to be
induced by fibrosis generated in the contused lung.
Retrospective chart review of 94 pts (less than 50 yo) with isolated pul
contusion defined by cxr and iss of <25. 79% of the pts had a good
outcome and 21% a bad outcome as defined by pneumonia
2%,atelactasis(needing bronch) 16%,effusion *%,bronchopleural
fistula 5%,empyema 2%, bacteremia 1%.
Poor outcome predicted by (univariate analysis) 1. pul contusion on
admission cxr, hypoxia on admission, need for chest tube, high chest
tube drainage, hypoxia on admission (po2<70 or po2/fiO2<250). On
multivariate analysis only po2/fio2<250 was an independent predictor
of poor outcome. There was no mortality.
Conclusion: Isolated pul contusion causes no mortality and is
predicted by low P/F ratios.
Criticism: No clear def of how the pts were defined as having pul
contusion’. No controls. Retro chart review with inherent bias.
© Copyright 2006 – Eastern Association for the Surgery of Trauma
Kollmorge
n (*2)
33
Balci
34
1994
2005
Flail Chest (7)
Relihan
1973
35
Design of Study: Retrospective single trauma center over 5 years of
all trauma patients with pulmonary contusion defined radiologically or
by the presence of flail chest. Type:
Observational_X__Cohort___Prevalence___Case Control___
Number of Patients: 100 consecutive patients Human__X__ or
Animal_____ Results: 97% of injuries blunt. 52% required intubation.
Overall 10% mortality with 70% mortality attributed to a direct
consequence of pulmonary failure or lung injury. Flail chest in 17%
with 30% mortality. ISS and transfusion requirements higher and GCS
and PaO2/FiO2 ratios lower in non-survivors. On regression patient
age, oxygenation 24 post admission, resuscitation volume correlated
with mortality. Of note, correlation between resuscitation volume and
ISS significant (p<0.01)but correlation between resuscitation volume
and oxygenation was not p(0.49). Statistical Methods / Significance:
One way ANOVA and multivariate regression analysis. P<0.05
Conclusions / Recommendations of Study: Outcome of pulmonary
contusion is dependent on a number of variables including the
severity of pulmonary injury Justification grading: Limited number of
patients, regression data overfit into limited data set which partly
explains inability to narrow variable set. Also key variables not
included in regression or based on even more limited subsets
because of inadequate data.
3
Kollmorgen DR, Murray KA:
Predictors of mortality in
pulmonary contusion. Am J Surg
1994; 168:659-64
Restrospective review of 107 patients with PC. Perfusion scans were
done and a contusion score was utilized ranging from 1 to 9, where
9 represented entire lung contusion. Mortality was 15%. Mortality
was predicted by age > 60, ISS>25, transfusion > 4 untis, paO2/FiO2
<300, concurrent flail chest and contusion score >7. (all p<.05)
3
Retrospective review of 85 cases: Results:.
3. Age and gender did not affect mortality.
4. Left lateral flail was more common than anterior or right sided.
5. Hypovolemia and pulmonary infection predominated as
complications.
6. Patients who died more than 48 hours after admission had cranial
Balci AE, Balci TA, Eren S, et al:
3
Unilateral post-traumatic
pulmonary contusion: findings of a
review. Surgery Today. 2005,
35:205-210
Relihan M, Litwin MS: Morbidity
and Mortality Associated With
Flail Chest injury: A Review of 85
Cases. J Trauma. 1973; 13:66371
© Copyright 2006 – Eastern Association for the Surgery of Trauma
Schaal
36
1979
Schall MA, Fischer RP, Perry JF:
The Unchanged Mortality of Flail
Chest Injuries. J Trauma. 1979;
19:492-6
3
injury 63% of the time and multiple fractures 50% of the time.
Pulmonary infection was felt to directly contribute to the deaths in
50% of the group. 56% were hypovolemic at some point during the
hospitalization. 25% had significant UGI bleeding from ulcer disease.
7.In comparing patients with and without head injury, death was more
common in the head injured group (68 vs. 19%). Pulmonary
complications were more common in the head injured group. (53% vs.
18%).
8. Pseudomonas and Staph aureus were the predominant organism
of pulmonary infections amongst survivors and non-survivors.
9. A. auregonese, P Vulgaris, E.Coli, and K. pneumonia were more
common (p<0.01) in patients who did not survive.
Stats:Means, percentages, method sometimes omitted from method
section and graphs
Conclusions:
1. Recognition as a multiply injured group.
Multidisciplinary approach of skilled, trained physicians, etc. to avoid
therapeutic omissions and excesses.
Retrospective review of 685 patients with thoracic trauma 1968-77 vs
historical controls. Mortality changed significantly for those patients
with one or more major extrathoracic injury whose major thoracic
injury was a hemothorax. Conclusion: main determinant of mortality
was shock of extrathoracic origin and head trauma. Stat methods not
provided.
© Copyright 2006 – Eastern Association for the Surgery of Trauma
Landercas
per
37
Beal
38
Freedland
39
1990
1985
1984
Freedland M, Wilson RF, Bender
JS, et al: The Management of
Flail Chest Injury: Factors
Beal SL, Oreskovich MR: Longterm Disability Associated with
Flail Chest Injury. Am. J. Surg.
1985;150:324-6.
Landercasper JL, Cogbill TH,
Lindesmith LA: Long-term
Disability after Flail Chest Injury. J
trauma. 1984; 24:410-14
3
3
2
Design: Retrospective chart review and prospective observations. Of
62 original patients, 32 were followed up. The rest died or were lost to
follow up. 26 had CXR's. 21 had spirometry. 20 had CO diffusion
study. 20 had dyspnea index. Results: 43% fully employed, 7%
changed profession, 11% part-time and 39% not employed. All CXR's
abnormal. 46% could not expand chest > 5cm. Spirometry showed
24% with obstructive airway changes, 20 % with restrictive findings
and 15% with both. Vital capacity normal in 57% who were on vent
and 22% of those off vent. CO diffusion normal in 90%. Mild dyspnea
in 50% and moderate in 20%. Statistics: None. Conclusions: Impaired
pulmonary function in most patients. Dyspnea in 70%. Pain in 49%.
80% with abnormal dyspnea index. Spirometry abnormal in 57%.
Return to normal work 43%. Strengths: Not many previous studies
looking at long term disability in patients with flail chest. This is a start.
Weaknesses: No information on preinjury function or employment or
activity. NO explanation of why all 32 available patients didn't get all
of the objective studies done. No discussion of how other injuries may
have affected the patients' ability to work.
Retrospective review: 20 patients with flail chest and associated
intrathoracic injuries, pulmonary contusion, hemothorax, and
pneumothorax were followed in an outpatient setting from 50 to 732
days following injury. Group I (11), those with no extra-thoracic injury,
33% fully recovered and 67% had permanent sequelae after flail
chest injury. One patient in Group I was not evaluated due to his
placement in a nursing home. Group II (9), includes extra-thoracic
injuries which were not thought to contribute to outcome, 40% were
fully recovered and 60% had permanent sequelae. One patient in
Group II was not evaluated due to his presence in an extended care
facility. Two groups were compared using the chi-square or Student’s
t test. Conclusion: The most common long-term problems after flail
chest injury are persistent chest wall pain, chest wall deformity, and
dyspnea on exertion.
Retrospectiive review of 57 patients.
Results: factors affecting outcome: etiology; age, extent of flail; assoc
pulmonary contusion, HPTX, assoc. injuries, ISS.
© Copyright 2006 – Eastern Association for the Surgery of Trauma
Gaillard
40
Albaugh
41
Athanassi
adi
42
3
Numbers don't add up: more chest injuries than there are patients:
some had multiple injuries: not addressed. Self-fulfilling conclusion:
more injured patients had higher mortality; no matched control group
without chest trauma. Age was not addressed. No mention of
associated injuries in the chest trauma patients
Recommendations: unsupported: fluid restriction; pain control
3
1990
2000
Allbaugh G, Kann B, Puc MM, et
al: Age-adjusted Outcomes in
Traumatic Flail Chest Injuries in
the Elderly. Am. Surgeon. 2000;
66:978-81.
3
58 pts who had flail chest were included in the retrospective chart
review. They were divided into 2 groups: under 55yo(32pts) and over
55yo(26pts).
No difference in groups re:ISS,LOS, vent days, head injury,
tracheostomy, pneumonia development, ARDS. Older group has
higher mort 58% vs 16%. Mort increases 132% for every 10 yr
increase in age. Wicoxon t test. X2 and logistic regression used. 95%
confidence interval used.
Conclusion: Age is predictor of outcome with flail chest and shows
increased mort.
Criticism: Retrospective chart review without any controls. The two
groups are not very comparable: many more males in first group.
Retrospective review. Main factors correlating with adverse outcome
(p,>05) were ISS and presence of associated injuries. Age and
hemopneumothorax did not affect did not affect mortality but did
influence length of stay. Main findings are as expected.
Affecting Outcome. J Trauma.
1990; 30:1460-68.
Gaillard M, Herve C, Mandin L, et
al: Mortality Prognostic Factors in
Chest Trauma. J Trauma. 1990;
30:93-6.
2004
Athanassiadi K, Gerazounis M,
Theakos N: Management of 150
flail chest injuries: analysis of risk
factors affecting outcome.Eur J.
CT Surg.2004; 26:373-6.
© Copyright 2006 – Eastern Association for the Surgery of Trauma
1974
Richardson JD, Franz JL:
Pulmonary contusion and
hemorrhage – Crystalloid versus
colloid replacement. J Surg Res
1974; 16:336
Fluid Management (9)
Fulton
1973 Fulton RL, Peter ET: Physiologic
effects of fluid therapy after
43
pulmonary contusion. Am J Surg
1973; 126:773-7
Trinkle
1973 Trinkle JK, Furman RW:
Pulmonary Contusion:
44
Pathogenesis and effect of
various resuscitative measures.
Ann Thorac Surg 1973; 16:568-73
Fulton
1974 Fulton RL, Peter ET:
Compositional and histologic
45
effects of fluid therapy following
pulmonary contusion. J Trauma
1974; 14:783-90
Richardso
n
46
2
An
2
An
Changes in nl lung with opposite lung injury. Shows injured lung
releases systemic factors that damage normal lung.
AN
Jadad
3
1
2
An
Experimental pulmonary contusion to RLL. Crystalloid and Dextran
caused lesion to be larger than colloid. Lasix and PEEP caused lesion
to be smaller to statistically significant degree. Decadron had no
effect on contusion size. No stat. sig. Difference when RLL weight to
body weight index used.
3 limb dog study with experimental PC. Contused lung doubles its
weight due to blood Fluid resuscitation increases the percentage of
water in the contused lung over control groups resulting in congestive
atelectasis.. This is unchanged whether or not the animal has
hemorrhagic shock induced and resuscitated. Well designed study
with statistical significance.
Prospective randomized animal model of 34 dogs. Results:
1. Plasma protein levels are progressively diminished in animals
receiving volume replacement with crystalloid.
2. Animals exhibited declining arterial po2 levels with
administration of Lactated Ringers at 90cc/kg with 30cc/kg
blood loss as compared to matched plasma replacement.
3. Lung water increases significantly with administration of LR at
both 30cc/kg and 90cc/kg compared to plasma.
4. Pathology exhibited alveolar disruption, hemorrhage, and
interstitial edema in all groups. In plasma administered
animals, hemorrhage was minimal and edema described as
mild to moderate. In LR infused groups, interstitial edema was
increased, there was more eosin-staining edema fluid with
increased rate of infusion and the amount of edema outside of
the central zone of contusion was likewise greater. Statistical
methods/significance:P<-.01 to 0.5 Wilcoxon Rank Sum Test
Conclusions: Plasma replacement was superior to RLS replacement
of volume. Rate of replacement of RLS also affected the results.
Evaluation: Animal study. Delayed studies not done to see if
© Copyright 2006 – Eastern Association for the Surgery of Trauma
Bongard
47
Johnson
(*2)
48
Kollmorge
n (*2)
49
1986
1984
Johnson JA, Cogbill TH:
Determinants of Outcome after
Pulmonary Contusion. J Trauma
1986; 26:695-7
Bongard FS, Lew FR: Crystalloid
resuscitation of patients with
pulmonary contusion. Am J Surg
1984; 148:145-9
3
3
1994
Kollmorgen DR, Murray KA:
Predictors of mortality in
pulmonary contusion. Am J Surg
1994; 168:659-64
differences resolve.
A Retrospective review of 109 patients with PC: attempted to
correlate PaO2/FiO2 ratio with plasma oncotic pressure in survivors
and non-survivors:
Results:
1. No correlation between PaO2/FiO2 and Plasmo oncotic
pressure.
2. No p-traumatic difference in PaO2/FiO2 between survivors and
non-survivors.
Conclusion: Pulmonary dysfunction after contusion is unrelated to
hemodilution. (Use of crystalloid does not affect outcome) P.C. is not
a progressive lesion unless pneumonia supervenes.
Justification: - retrospective study does no support conclusions made.
Retrospective case series of 86 patients . Results: Mortality was
significantly greater (p<0.05) in patients with ISS greater than or
equal to 25, initial GCS less than or equal to 7, transfusion of > 3units
of blood and pO2/FIO2 <300. Conclusions: Mortality correlated with
degree of hypoxemia on admission, extrathoracic injury , particularly
head trauma and overall severity of injury.. Mortality was not
correlated with either the presence of shock or amount of intravenous
fluid administration. Concomitant flail chest did not lead to increased
mortality, but did increase the incidence of mechanical ventilation
(p<0.05). The extent of contusion assessed on admission CXR was
not predicative of mortality or the need for intubation. Stats: Chisquare analysis of two proportions with Yates’correction. Level of
confidence was defined p<0.05.
© Copyright 2006 – Eastern Association for the Surgery of Trauma
Cohn
50
1997
Cohn SM, Zieg PM: Resuscitation
of pulmonary contusion: Effects of
a red cell substitute. Crit Care
Med 1997; 25:484-91
2
AN
Design: Cohort study with 10 pigs. Results: More decrease of
hemoglobin with crystalloid. SVO2 unchanged with crystalloid but
decreased with Hb substitute. Had increased MPAP greater with Hb
substitute than crystalloid. Compliance decreased more with Hb
substitute than crystalloid. Increased lesion size with Hb substitute on
CT scan. Statistical methods: Tukey's difference test for post oc
comparisons p<0.05. Conclusions: Increased hemorrhage with Hb
substitute vs. crystalloid. Compliance decreased more with Hb
substitute vs. crystalloid. Overall, Hb substitute did not perform well
compared to crystalloid. Strength:None Weaknesses: Study of Hb
substitute affect on lungs, not pulmonary contusion. There were no
controls who were not contused. Study only lasted 4 hours. Did not
see hypoxemia in either group; why? Used static rather than dynamic
compliance.
© Copyright 2006 – Eastern Association for the Surgery of Trauma
Cohn
51
1997
Cohn SM, Fisher BT:
Resuscitation of pulmonary
contusion: Hypertonic saline is not
beneficial. Shock 1997; 8:292-9
1
Jadad
4
AN
Prospective randomized trial. Jadad scale 4 (1,0-doubleblind,1,1,1)18
pigs were used to evaluate the effects of pulmonary contusion and
resuscitation with Normal saline (8pigs,NS, 90cc/kg) or
7.5%saline(HTS , 4cc/kg,10pigs). The pigs were also bled 30cc/kg
and resuscitated at t=20 mins. Resuscitation was continued for 20
mins and then the pigs received maintenance fluids till 4 hrs. At 4 hrs
the pigs were Ct scaned to obtain injury volume and then sacrificed to
measure wet and dry lung weight. ANOVA used , p<0.05 null
rejected.
HR was same for both groups. MAPs were lower at 40 and 120 mins
for HTS group. NS resus returned bp to baseline. Cardiac index was
also lower for HTS upto 60 mins compared to NS.NS returned CI to
baseline. Thus O2 extraction was lower in the HTS group and never
returned to baseline as with NS.
Compliance worsened in both groups similarly.
CT lesion volumes and dry/wet lung wts remained same for both the
groups.
Conclusion: Small volume hypertonic resus does not decrease lung
injury.
Criticism: Time studied (4 hrs) might be too short. 90cc/kg too much
wrt 4 cc/kg for the hypertonic saline.
© Copyright 2006 – Eastern Association for the Surgery of Trauma
Ventilatory Support
1982
Richardson JD, Adams L:
Selective management of flail
chest and pulmonary contusion.
Ann. Surg 1982; 196:481-6
2
AN
3
3
1998
Pulmonary Contusion (4)
Shin
1979 Shin B, McAslan C: Management
of lung contusion. Am Surg
1979;45:168-75
52
Richardso
n
53
Moomey
54
Moomey CB, Fabian TC:
Cardiopulmonary function after
pulmonary contusion and partial
liquid ventilation. J Trauma 1998;
45:283-90
Retrospective study of 132 patients immediate intubation and
ventilation with PEEP for every lung contusion . Single limb study
Progressive hypoxemia and pulmonary deterioration were not seen.
Deaths due to brain injury or sepsis . Conclusions: early intubation
and ventilation with peep minimizes development of interstitial edema
and alveolar hemorrhage. Methodologically flawed: retrospective, no
statistical validation, small numbers, no correction for severity of
illness. Conclusion can’t be supported by the data.
Retrospective study (retrospective review of prospectively accrued
data) of 427 patients with FC-PC.
95 pts. Had FC. (86% of those also had PC) 135 pts. had PC without
FC. Treatment modalities varied by physician judgment., including
fluid restriction. 99 intubated. 328 not.
Results: Half the FC patients were intubated and 20% of the PC
patients were also. The intubated patients had a higher mortality but
were more severely injured. Overall mortality 6.5% with ¼ of that
due to pulmonary complications.
Conclusions :Use ventilatory support only as a last resort with specific
indications.
Justification: Mostly expert opinion . No statistical analysis.
Design: Cohort study with 23 pigs. Results: Confirmed decreased
PaO2/FIO2 ratio and increased PVR, increased dead space,
increased shunt in injured animals. The increase of peak inspiratory
pressure was greater with partial liquid ventilation(PLV) than with
PEEP. Increased PEEP caused a better increase of PaO2/FIO2
ration and a better decrease of dead space than PLV. Shunt fraction
was lower and compliance higher for PEEP than PLV but difference
was not statistically significant. PEEP caused a decrease in Cardiac
index, stroke index and oxygen delivery; there was no change with
PLV. There was less hemorrhage in uninjured lung on PLV than on
PEEP. The injured lung had no histologic changes between the
treatment groups. Statistics: ANOVA and Fisher's t test; p=0.05
© Copyright 2006 – Eastern Association for the Surgery of Trauma
Riou
55
2001
Riou B, Zaier K: High-frequency
jet ventilation in life-threatening
bilateral pulmonary contusion.
Anesthesiology 2001; 94:927-30
2
Conclusions:Neither PLV nor PEEP was 100% effective. There were
advantages and disadvantages with both. Neither reversed increased
airway resistance caused by contusion. PEEP was better than PLV at
restoring PaO2 and decreasing dead space. PEEP was as good at
PLV at correcting PaCO2, compliance and shunt fraction. PLV is
better than PEEP at maintaining cardiac index, stroke index and
oxygen delivery. Strengths: Good controls. Weaknesses: Ventilator
strategy did not include low tidal volumes. Could this have caused
injury to both groups and been attenuated in the PLV group. Was
PEEP of 25 needed? Total treatment time lasted only 2 hours and
there was only 30 minutes between PEEP changes. Only single dose
of perflubron was given and there was no account for evaporation; not
using PEEP with PLV as is usually done may have caused more
evaporative losses.
Report on 9 patients: no controls. HFJV used after conventional
ventilation failed: lung protective strategies not addressed. 4/9
patients died: all from "severe head injury": no information on the
effects of HFJV on the head injury. HFJV was successful "salvage"
therapy for resistant hypoxia.
© Copyright 2006 – Eastern Association for the Surgery of Trauma
Flail Chest - Ventilatory Support vs. Conservative Treatment (10)
Diethelm
1971 Diethelm AG, Battle W:
3
Retrospective cases series review: Results: 75 patients were treated
Management of Flail Chest Injury:
by both internal and external means of stabilization. Early
56
A Review of 75 Cases. Am
stabilization was achieved by endotracheal intubation and positive
Surgeon. 1971; ___:667-70
pressure ventilation in 56 patients usually lasting 7 to 14 days.
External fixation was required in 19 patients by using towel clips,
sternal wiring or sandbags. Nine of the patients died none of which
were related to hypoxia or thoracic instability. No statistics identified.
Conclusions: 75 patients were treated by both internal and external
means of stabilization. Early stabilization was achieved by
endotracheal intubation and positive pressure ventilation in 56
patients usually lasting 7 to 14 days. External fixation was required in
19 patients by using towel clips, sternal wiring or sandbags. Nine of
the patients died, none of which were related to hypoxia or thoracic
instability. Justify grading: observational study without stats. Historical
interest. No usable conclusions today.
Trinkle
1975 Trinkle JK, Richardson JD, Franz 3
Retrospective review of 30 patients. Results:
JL, et al: Management of Flail
1. The groups were comparable with respect to age, mechanism,
57
Chest Without Mechanical
number and types of organs injured, requirement of operations,
Ventilation. Ann. Thoracic Surg.
rib fractures, and ED stability.
1975; 19:355-62.
2. Tracheostomy was also the preferred method of intubation in
group 1.
3. Avg. # of ventilator days was 22.6 in group 1 and 0.6 in group
2 (p<0.005)
4. Group 1 was hospitalized 22.6 days avg. vs. 9.3 in group 2.
(p<0.005)
5. 21% mortality in Group 1 vs. 0% in group 2. (p< 0.01)
6. 23 complications in Group 1 vs. 2 in group 2. (p<0.001)
Stats:Wilcoxon Rank Sum Test/ Chi Square Test p<0.01
Conclusions/Recommendations:
1. Internal stabilization is not warranted in all cases of flail chest
2. Mandatory tracheostomy and ventilation is not needed.
Justify grading. Strengths/weaknesses
Compared two methods being practiced in a large center by different
areas of the hospital supervised by two different groups of physicians.
© Copyright 2006 – Eastern Association for the Surgery of Trauma
Shackford
58
1976
Christenss 1979
on
59
Christensson P, Gisselsson L,
Lecerof H, et al: Early and Late
Results of Controlled Ventilation
in Flail Chest. Chest. 1979;
75:456-60.
Shackford SR, Smith DE, Zarins
CK, et al: The Management of
Flail Chest. Am. J. Surg. 1976;
132:759-62.
2
2
Methods significantly different between groups. The data are rather
convincing, but the small numbers of patients and the study design do
not allow major confidence in most of the statements.
Case control group of ventilated vs non-ventilated patients with flail
chest. Failure of mechanical ventilation to improve survival with flail
chest is due to complications of vent support. Groups well matched
for severity of thoracic injury and overall. Mechanical ventilation
should be used to correct abnormalities of gas exchange rather than
to overcome instability of chest wall. Endpoint is normalization of
PaO2, shunt and Aa gradient. Well identified groups and stat. sig.
achieved but retrospective study with small numbers.
Single limb prospective observational study of 35 patients with FC. All
were treated with obligatory tracheostomy and IPPB for two to three
weeks. The goal was to stabilize the chest wall in a favorable position
for healing. Seven patients died of other injuries.
Results – 1-8 year PFTs revealed minimal to no impairment of
mechanics. Zenon perfusion revealed reduction in regional perfusion
in 5/35 patients.
Conclusion: Mandatory IPPB is useful in allowing healing and
preventing long term disability in patients with FC and paradoxical
respiratory movements.
Justify grading: small sample of patients in single limb study. Not
compared to a control group of non-vented patients.
© Copyright 2006 – Eastern Association for the Surgery of Trauma
Carpintero
60
Shackford
61
1981
1980
Shackford SR, Virgilio RW, Peters
RM, et al Selective Use of
Ventilator Therapy in Flail Chest
Injury. J. Thorac. Cardiovasc.
Surg. 1981; 81:194-201
Carpintero JL, Rodriguez Diez A,
Elvira JR, et al: Methods of
Management of Flail Chest.
Intens. Care Med. 1980; 6:217-21
2
3
Non-randomized observational study of 30 patients: Two groups of
patients were identified. All received initial therapy identically, but
those who progressed to mechanical ventilation were designated
Group B. Age, initial vital signs, number of ribs fractured,
hemopneumothoraces, evidence of cardiovascular injury/anomaly by
EKG, head injury, initial po2 and pCO2, and need for abdominal
procedure were statistically the same.
1. The ventilated group had a statistically higher incidence of
pneumonia and sepsis.
2. The average stay was 3.2 for the nonventilated group vs. 11.7
for the ventilated group (p<0.01)
3. There were no statistically significant parameters in patients
who received surgical fixation of fractures vs. those with flail
chest that did not.
4. Static compliance measurements were the only variable in
which survivors were statistically different than nonsurvivors.
(56 vs/ 25 p<0.01)
Stats: Student T and Chi Square ; p< 0.01
Conclusions:
1. Conservative management can be successful for flail chest
and has a lower morbidity and mortality.
2. Mechanical ventilation with IMV + PEEP if the patient cannot
be oxygenated conservatively.
3. The static compliance is a good prognostic indicator.
4. Early surgical fixation is needed in the very unstable chest.
Justify grading. Strengths/weaknesses
Observational study in which patients who were not doing well and
required mechanical ventilation were stratified as a separate group.
Small numbers. No real criteria for stabilization. Arms of study not
random. Conclusions not well supported.
Design of Study: Prospective evaluation of flail chest patients in a
treatment protocol for limited use of mechanical ventilation. Group I
patients had severe pulmonary dysfunction. Group II patients had no
pulmonary dysfunction on admission but did require temporary
ventilatory support for an associated injury. Group III had no
© Copyright 2006 – Eastern Association for the Surgery of Trauma
pulmonary dysfunction on admission. Blunt injuries only. Type: Cohort
study of 36patients. . Group I = 13, Group II = 7, Group III = 16
Results: Complication rate in Group I significantly higher than others
at 40% with pneumonia occurring in 69%. Mortality rate in group I was
15%. Group II duration of ventilation <24 hours in all but one with no
deaths. Group III patients 94% didn’t require ventilatory support.
Decreased proportion of flail chest patients ventilated from 74% in
earlier study to 38% in this study. Mortality rate also decreased from
14% to 8% from earlier to current period. Statistical Methods /
Significance: Student’s t test. P<0.01. Conclusions /
Recommendations of Study: Ventilatory support should be reserved
for patients who manifest some degree of pulmonary dysfunction
such as hypoxemia, increased intrapulmonary shunt fraction or
clinical respiratory distress. Justification grading: Limited study but
defined treatment protocols and relatively homogenous groups.
Ventilator protocol with 15 mg/kg tidal volumes would in and of itself
contribute to lung injury.
© Copyright 2006 – Eastern Association for the Surgery of Trauma
Dittmann
62
Miller
63
Odelowo
64
1983
1982
Dittmann M, Steenblock U,
Kranzlin M, et al: Epidural
Analgesia or Mechanical
Ventilation for Multiple Rib
Fractures. Intensive Care Med.
1982; 8:59-92
3
3
3
Miller HA, Taylor GA, Harrison
AW, et al: Management of Flail
Chest. Can. Med. Assoc. J. 1983;
129: 1104-1107
1987
Odelowo FO: Successful
Management of Flail Chest
Without the Use of a Volume
Ventilator. J. Med. East.
Afr.1987; 64:836-844
Prospective analysis of treatment protocol. For 283 patients. Results:
155 patients were treated with primary ventilation, 112 patients with
primary epidural analgesia, and 16 patients with general anesthesia.
Primarily ventilated patients were treated for an average of 13.5 days
in the ICU, spent 26.2 days in the hospital with 22 dying
predominantly due to pulmonary causes and 16 solely due to nonpulmonary causes. 21 of the 155 primarily ventilated patients could
be extubated early with thoracic epidural analgesia. Spontaneously
breathing patients receiving thoracic epidural analgesia spent an
average of 6.1 days in the ICU and a total of 17 days in the hospital.
Five of the patients treated primarily with epidural analgesia needed
secondary ventilation. Stats: none supplied. Conclusions: The
severity of gas exchange abnrmality, not mechanical defect is the
indication for ventilatory support. For patients with only moderate gas
exchange abnormality , spontaneous breathing with epidural
analgesia is preferable. This is a descriptive study of a protocol.
Since groups are not homogenous no statement can be made
regarding relative effectiveness of each modality.
Conclusion that not all patients with flail chest need mechanical
ventilation is supported. However in the group that was ventliated,
only 2 (out of 57) were intubated because of pulmonary/respiratory
problems. The use of diuretics, colloids, fluid restriction and steroids
was not controlled. Patients grouped retrospectively; few had ISS
recorded.
Clinical series of 7 flail chest patients treated with intercostal nerve
block and chest stabilization using adhesive plaster across the flail
portion. Pts received O2,and nasotracheal suction along with
antibiotics.
One pt expired. 2 pts could not tolerate the plaster (1-increase ICP,1pregnant). Hospital course 11-38d. No statistics used.
Conclusion: Developing countries should use the management
scheme since it produces good results.
Criticism: No evidence that this scheme is any better than any other
non-vent management. Not clear that their result are better than no
© Copyright 2006 – Eastern Association for the Surgery of Trauma
Velmahos
65
2002
Velmahos GC, Vassiliu P, Chan
LS, et al. Influence of Flail Chest
on Outcome Among Patients with
Severe Thoracic Cage Trauma.
Int. Surg. 2002; 87:240-44
Modes of Ventilatory Support (9)
2
management at all.
Prospective comparative study of 60 patients with thoracic trauma. 22
pts had flail chest and 68 rib fractures without flail. Outcomes looked
at were, mort, resp complications (pneumonia and ARDS), need for
ventilation, and length of ICU and hospital stay. Student t-test, Chisquare or Fischer’s exact test was used. P<0.05 was considered
significant.
Flail pts were similar to the rib-fracture-only pts except for higher ISS.
Flail pts needed vent support more(despite similar rates of lung
contusion) (86% vs 42%),and had more resp complications (64% vs
26%overall; pneumonia 55%vs 24% ; ARDS 27% vs 9%). They also
had longer hospital stays(28d vs 17 d) and ICU stays (20d vs 9 d).
Conclusion: Pts with flail chest need intubation and develop pulm
complications.
Criticism: Pts with flail chest had higher ISS scores and the
calculation of pul contusion volume can be subjective.
© Copyright 2006 – Eastern Association for the Surgery of Trauma
Sladen
66
1973
Sladen A, Aldredge CF, Albarran
R: PEEP vs. ZEEP in the
Treatment of Flail Chest Injuries.
Crit. Care Med. 1973; 1:187-91.
2
Prospective serial controlled study of 9 patients, patient serving as
own control:
Results:
1. PO2 improves in nearly all patients with the addition of PEEP
of 10 or 15 (t=5.15. p<0.001)
2. No change in physiologic dead space measurement with
administration of peep at 0, 10, and 15.
3. Rib alignment “usually improved” with PEEP.
Stats:Student’s paired T test, p<0.001
Conclusions:
1. Oxygenation improves with application of PEEP. The authors
state it is the FRC that is responsible.
2. PEEP can affect cardiac output.
3. Rib fracture alignment is improved with PEEP.
Justification:
1. Very small study in which patients serve as their own controls
showing that oxygenation is improved with PEEP and that it is not
secondary to changes in the physiologic dead space. These
conclusions are supported.
2. The conclusion that rib alignment is improved is weak as there is
no real description or quantitative data. All patients had a
tracheostomy and were placed on the ventilator. This is not truly
applicable or acceptable in current practice standards.
3. Some of the pO2 were in the 200-300 range. ? need for vent/trach
in this group
4. Statement regarding cardiac output is based on experience with
only one patient in this group. I think we are now aware that this is
true from other authors, but this study does not support this well.
© Copyright 2006 – Eastern Association for the Surgery of Trauma
Cullen
67
Pinella
68
1975
1982
Cullen P, Modell JH, Kirby RR, et
al: Treatment of Flail Chest. Arch
Surg. 1975; 110:1099-1103
Pinella JC: Acute Respiratory
Failure in Severe Blunt Chest
Trauma. J Trauma. 1982;
22:221-225
3
3
Retrospective review of prospective protocol, cohort study of 144
patients. Results: The size of flail chest segments were measured
and classified as small (<100cm2), medium (101-199 cm2) and large
(>200cm2) with the size of the flail chest segment determining the
need for ventilatory support. Aggressive medical management did
not prevent most patients (79%) with large flail segments (>200 cm2)
from requiring intubation. The initial Pa02/FIO2 and the number of
associated extra-thoracic injuries did not correlate significantly with
mortality. Further, the presence of pulmonary contusion, number of
fractured ribs and hemopneumothorax were not significant
determinants of death. When comparing continuous mandatory
ventilation to intermittent mandatory ventilation in the two study
groups, the number of days on respirator, thoracic injuries, level of
PEEP used did not significantly vary, but the course of respiratory
failure was improved with IMV. Stats: Comparisons for determinants
of mortality, use of ventilatory support and the degree of severity by
size of the flail segment used a fourfold table of X2. Comparison of
the degree of respiratory failure in the two historical periods was
accomplished by the standard error of differences between the means
and the probability related to multiples of standard deviation or error
for a normal distribution.
Retrospective human study with significant confounding: groups
"contaminated" with criteria from other groups; patients weaned
differently, then claiming weaning on IMV was better: CMV patients
NOT given same spontaneous breathing trial at the same time as IMV
group. Conclusions not justified by their methods.
© Copyright 2006 – Eastern Association for the Surgery of Trauma
Hurst 69
Hurst
70
1989
1985
Hurst JM, Branson RD, Davis K,
et al: Cardiopulmonary Effects of
Pressure Support Ventilation.
Arch Surg.1989; 124:1067-1070
Hurst JM, DeHaven CB, Branson
RD: Comparision of Conventional
Mechanical Ventilation and
Synchronous Independent Lung
Ventilation (SILV) in the
Treatment of Unilateral Lung
Injury
2
2
Prospective single limb observational study of eight patients with PC
+/- FC who were “failing” conventional ventilation and were placed on
SILV. ) Significant improvements were obtained in PaO2 ( 72+8.7 to
153+37; p<.005) and shunt fraction (28+3.5 to 12.6+2.5; p<.005) No
significant changes occurred in cardiac output, peripheral resistance
or oxygen extraction index. Seven of the eight patients survived.
Though this study was prospective, selection was non-random and no
control group was studied. However , some support is lent to the
claim that appropriate patients with severe unilateral disease who are
failing with a single ventilator may do better with independent lung
ventilation.
Conclusion, that patients with flail, pulmonary contusion, should be
placed on PSV,is not supported. Patients not randomized, no
controls. No data collected was shown to be statistically significant.
Some observations on the changes in pulmonary mechanics after
instituting PSV are beneficial.
© Copyright 2006 – Eastern Association for the Surgery of Trauma
Tzelepis
71
1989
Tzelepis GE, McCool FD,
Hopppin FG: Chest Wall
Distortion in Patients with Flail
Chest. Am. Rev. Resp. Dis. 1989;
140:31-37.
2
Design of Study: Cohort study of hemodynamically stable flail chest
patients on mechanical ventilation able to breathe without ventilatory
assistance for several minutes versus normal control volunteers.
Breath to breath variability in patterns of chest wall motion over 10
breaths was assessed by measuring the angle between
displacements of the rib cage in various positions. Type: Cohort study
of 9 Patients. in ventilated flail chest and 4 in control Results: There
was a greater degree of chest wall distortion in flail chest wall patients
the greater the loading of the ventilator, thus more distortion with
spontaneous breathing IMV versus CPAP through a ventilator
demand valve circuit versus CPAP through a high flow gas system.
Statistical Methods / Significance: Paired t test to determine
significance of pressures and angles. p<0.05. Conclusions /
Recommendations of Study: The distortion imposed by ventilators
increases the work of breathing in flail chest patients and may
contribute to difficulty breathing. Justification grading: Conclusion not
supported by study evidence. Degree of distortion of chest wall
interesting, but in my opinion the ability to wean ventilator or recover
from flail chest injury is related to the underlying parenchymal lung
injury, the inflammatory response and the presence or absence of
complications and not the paradoxical motion of the overlying chest
wall
© Copyright 2006 – Eastern Association for the Surgery of Trauma
Rouby
72
Ip-Yam
73
Tanaka
74
1992
1998
2001
Rouby JJ, Ben Ameur M, Jawish
D, et al: Continuous Positive
Airway Pressure (CPAP) vs.
Intermittent Mandatory Pressure
Release Ventilation (IMPRV) in
patients with Acute Respiratory
Failure. Intensive Care Med.
1992; 18:69-75.
Ip-Yam PC, Allsop E, Murphy J:
Combined high-frequency
ventilation in the treatment of an
acute lung injury Ann Acad Med,
Singapore. 1998; 27:437-41.
Tanaka H, Tajimi K, Endoh Y, et
al: Pneumatic Stabilization for
Flail Chest Injury: An 11-Year
Study. Surg. Today. 2001; 31:1217.
2
N/A
2
2 Cohort series, one serving as control comprised of a retrospective
review of charts of 59 pts with flail chest. (historical controls)
One group of pts with flail chest were treated with mechanical
ventilation as the primary treatment. A later group admitted to the
same institution was treated with CPAP and pulmonary therapy in an
attempt to avert intubation. The first group had 39 pts and the 2nd 20.
Mort was lower in the 2nd group (51vs21%)..non significant
statistically. Hemorrhage and brain injury caused 15 deaths. The
An anecdotal report of the successful use of high frequency jet
ventilation in the treatment of resistant hypoxia consequent to multiple
thoracic injuries.
Design: Prospective cohort study with 16 patients divided into two
groups. All patients in respiratory failure; most with either pneumonia
or pulmonary contusion. Group 2 was supposed to have abnormal
spontaneous breathing either from flail chest, quadriplegia or fentanyl
sedation. Each patient in both groups was put on CPAP and IMPRV
for an hour each; the order was random. Results: Only parameter
different between groups 1&2 was pCO2 which was lower in Group 1;
authors attribute this to less efficient spontaneous breathing in group
2. IMPRV significantly increased minute ventilation in group 2 patients
but provided no change in group 1 patients. Peak inspiratory pressure
was higher in IMPRV in both groups. Statistics: Groups compared
using Mann-Whitney U test; Ventilator parameters compared using
student t test; respiratory and hemodynamic data were compared
using Kruskall and Wallis H test and Mann-Whitney U test.
Conclusion: IMPRV improves ventilation in patients who have poor
spontaneous respiration because of either flail chest or sedation or
paralysis. IMPRV caused decreased spontaneous respiration in group
1. Strengths: None. Weaknesses: Only 3 patients in Group 2 had flail
chest. Group 2 was too heterogenous. Each ventilator mode was tried
in the same patient for only an hour in a random order. Very poorly
designed study. No conclusions can be drawn from it.
© Copyright 2006 – Eastern Association for the Surgery of Trauma
surviving pts were identical in both the groups..same ISS,age and
gender. However, they had different rates of atelactasis and
pneumonia. The rates were lower in the 2nd group..(95vs 47% for
atelactasis; 70 vs 27% for pneumonia) The rate of CMV was higher in
the first group and the number of pts needing endotracheal intubation
was lower in the 2nd group. Fisher’s test used , CI>95% significant.
Conclusion:Pulmonary morbidity and the need for ETI is reduced by
the introduction of analgesia, CPAP and respiratory physical therapy.
Criticism: Trial is non-randomized and non-blinded. Bias may be
introduced.Difference in mortality could not be demonstrated.
© Copyright 2006 – Eastern Association for the Surgery of Trauma
Schweiger
2003
?
1
N/A
Animal study
Jadad
3
3
AN
2004
Schreiter D, Reske A, Stichert B,
et al: Alveolar recruitment in
combination with sufficient
positive end-expiratory pressure
increases oxygenation and lung
aeration in patients with severe
chest trauma. Crit Care Med.
2004; 32:968-75.
2
Schweiger JW, Downs JB, Smith
RA: CPAP Improves Lung
Mechanics After Flail Chest Injury.
Schweiger JW, Downs JB, Smith
RA: Chest Wall Disruption with
and without Acute Lung Injury:
effects of Continuous Positive
Airway Pressure Therapy on
Ventilation and Perfusion
Relationships. Crit Care Med.
2003; 31:2364-70.
2005
75
Schweiger
76
Schreiter
77
Gunduz
78
Prospective randomized lab investigation of 22 pigs. Three groups
ventilated on IMV: uninjured control; chest wall disruption only; chest
wall disruption and lung injury. Extensive measurments on IMV prior
to application CPAP:
Results: significant decrease in open units with chest wall disruption
and an even greater decrease with disruption + lung injury.
Applicaton of CPAP decreased shunt, increased # of open alveolar
units, reduced FiO2 requirements without impairment of cv function.
Conclusion: CPAP is beneficial for correcting alveolar closure and
VQ mismatch in both FC and FC with lung injury in animals.
Justification: well done prospective randomized study with good
statistics. Use of acid lung injury as a mimic to pulmonary contusion is
presumptive.. Otherwise, conclusions are well supported.
A retrospective analysis (n=17) of a protocol to use lung recruitment
strategy to improve oxygenation in patients with acute lung injury or
full ARDS secondary to pulmonary contusion. The temporary ( less
than five minutes) stepwise application of high insipiratory pressures
started with 50 cm H2O and progressed in 15 cm H2O increments
(range 50-80). Authors demonstrated increased paO2/FiO2 ratio,
aerated lung volume by CT scan and measured total lung volumes
(p<.05) Sample size was small though results statistically significant.
Effect on survival or total ventilator days could not be assessed with
sample size. Such protocols seem to have possible applicability to
patients with pulmonary contusion.
A prospective, randomized non-blinded comparison of non-invasive
(mask) CPAP to IPPV via endotracheal tube. (n=52 divided into two
limbs). Noninvasive CPAP led to a lower mortality (20%, 5/25 vs 33%
7/21 p<.01) and nosocomial infection rate (4/22, 18% vs. 10/21, 48%
p=.001) Mean pO2 was higher in the ET group initially ( 2 days
p<.05) but then equalized. A difference in the length of ICU stay
could not be demonstrated. Statistical validation well done.
Gunduz M, Unlugenc H, Ozalevli
M, et al: A comparative study of
continuous positive airway
pressure (CPAP) and intermittent
positive pressure ventilation
(IPPV) in patients with flail chest.
Emerg Med J. 2005; 22:325-9.
© Copyright 2006 – Eastern Association for the Surgery of Trauma
© Copyright 2006 – Eastern Association for the Surgery of Trauma
1975
Paris F, Tarazona V, Blasco E, et
al: Surgical Stabilization of
Traumatic Flail Chest. Thorax.
1975; 30:521-7
3
3
3
1978
Surgical Repair of Flail Chest (17)
Moore
1975 Moore BP: Operative Stabilization
of Non-penetrating Chest
79
Injuries. J. Thorac. Cardiovasc.
Surg. 1975; 70:619-630
Paris
80
Thomas
81
Thomas AN, Blaisdell W, Lewis
FR, et al: Operative Stabilization
for Flail Chest after Blunt Trauma.
J. Thorac. Cardiovasc. Surg.
1978; 75:793-801.
A retrospective review of 50 cases of chest wall stabilization.
Results: 11 deaths of which two were related to primary respiratory
failure. Ventilation via tracheostomy was used for less than 3 days in
eight patients.
Conclusions: operative stabilization prevents or reduces the use of
mechanical ventilation and lessens or avboids permanent chest wall
deformity.
Justification: Expert opinion only . No comparison to other options.
Observational study of 233 chest injured patients with 29 cases of
flail. Results:
1. Group I (internal stabilization) had a mortality of 73% due to
non-chest causes.
2. Group II had late surgical stabilization due to unstable medical
condition on presentation and had a 40% mortality.
3. Group III was stable and had early surgical repair and no
mortality.
4. Group IV had early surgical stabilization but also had internal
injuries to chest or abdomen approached operatively. Mortality
1 in 4 or possibly 2 in 4. Unclear.
Stats: None
Conclusions:
Surgical stabilization is helpful.
Justify grading: Small study. Groups clearly heteogenous. No real
statistical analysis. Conclusions not adequately supported.
Clinical series of 4 pts with flail chest treated with operative
stabilization. Pt 1 improved and was extubated in 48 hrs. Pt 2
improved her vital capacity and MIF but then died of an MI. Pt 3
improved his VC and MIF but died of hypoxic failure. Pt 4 was
extubated at nine days post op but had no preop VC or MIF done to
compare to post op values.
Conclusion: Internal stabilization of flail chest is advantageous
Criticism: Small series without good data to support the conclusion of
the authors. Cannot assume that the small improvements in pul
mechanics will translate into any real benefit for the patients.
© Copyright 2006 – Eastern Association for the Surgery of Trauma
Hellberg
82
1981
Hellberg K, deVivie ER, Fuchs K, 3
et al: Stabilization of Flail Chest
by Compression Osteosynthesis –
Experimental and Clinical Results.
Thorac. Cardiovasc. Surgeon.
1981; 29:275-81
Cases series, cohort study of 10 patients: Results: 2 patients with
type A flail chest (anterior type with unilateral or bilateral rib fractures
in the costochondral area with or without sternum fracture), 3 type B
(lateral type with serial segmental fractures), 4 type B (lateral type
with serial rib fractures) and one dislodged sternum fracture had 29
dynamic compressions plates implanted in the lateral or anterolateral
ribs; 2 compression plates utilized for sternum fixation; and 2 rib struts
for additional fixation in type A flail chest. All compression
osteosynthesis plates resulted in immediate stabilization of the
fractured rib and stabilization of the chest wall. 8 patients survived to
be successfully weaned from the respirator 3 to 14 days (mean 5.4)
after the stabilization procedure. The three deaths resulted from
injuries not related to the stabilization procedure. Stats not identified.
Conclusions: The use of compression osteosynthesis plates results in
marked reduction of pain, immediate stabilization and decreased
ventilator support time. This technique is particularly suited for lateral
or anterolateral serial fractures. Patients with bilateral rib serial
fractures close to the costochondral junction , plate osteosynthesis
can be difficult and chest wall stabilization is better achieved with one
or two rib struts. Justify grading: technical description; no comparison
to alternative therapies. No conclusions can be drawn.
© Copyright 2006 – Eastern Association for the Surgery of Trauma
1982
Schmit1981
Neuerburg
Menard A, Testart J, Philippe JM, 3
et al: Treatment of Flail Chest with
Judet’s Struts. J Thorac.
Cardiovasc. Surg. 1983; 86:300305
Sanchez-Lloret J, Letang E,
Matsu M, et al: Indicatons and
Surgical Treatment of the
Traumatic Flail Chest Syndrome:
An original Technique. Thorac.
Cardiovasc. Surgeon. 1982;
30:294-7.
Schmitt-Neuerburg KP, Weiss H,
Labitzke R: Indication for
Thoracotomy and Chest Wall
Stabilization. Injury. 1981; 14:2634
TA
3
85
Menard
84
SanchezLloret
83
1983
Galan G, Penalver JC, Paris F, et
3
1992
Galan
Two limb retrospective review of 50 patients with surgical chest wall
stabilization vs none. Mortality in operative group was ½ that of nonop group ( 36 vs 64%) Deaths in non-op group were due to
pulmonary and septic complications from prolonged vent support.
Conclusion: it is better to stabilize flail chest with rib plates than
pneumoatic stablization on ventilator. Weaknesses: - observational
study with no discussion of design, methods or statistics. No evidence
of randomization or homogeneity between two groups.
Retrospective review, cohort series Results: 7 cases of flail chest
were treated by rib fixation using extraperiostal plates. Of this group,
4 patients required “lung suture”, 2 diaphragm suture and 1
splenectomy. All patients were managed with IPPV with a mean
postoperative time of mechanical ventilation 15 days (variance 0 to 30
days). No deaths were directly attributed to extraperiostal plate
placement. Stats: None identified. Conclusions: Extraperiosteal rib
plates allow the fixation of 2 rib fracture sites with the same plate.
This rib fixation technique can be used with associated intrathoracic
lesions requiring emergency thoracotomy, thoracoabdominal trauma,
bilateral multiple rib fractures with moderate to severe paradoxical
motion of the chest wall and“flail chest syndrome”.
Prospective trial of use of Judets struts to operatively stabilize flail
chest in 18 pts.
There were 5 deaths in the series. 3pts were extubated in 24 hrs, 2 in
8 days,7 in the third week. Info not available for the rest of the pts.
Postop complications included 2 atelactases, 2 pneumonias, 1
pleurisy, 2 wound infections, 1 septicemia, 1 wire migration,1
brochoalveolitis. 6 pts had nl cxr’s, 8 had abnormalities. Only 3 pts
had PFTs and they were all restrictive.
Conclusion: Judets struts are better than other modes of operative
flail chest immobilization and obviate the need for ventilation.
Criticism: Conclusion not supported by data. There are high rates of
ventilatory support. No controls or comparison of other modalities are
presented. No reason given why these particular pts were chosen for
operative stabilization, other than request or preferences of MDs.
Design of Study: Retrospective review single trauma center of blunt
© Copyright 2006 – Eastern Association for the Surgery of Trauma
86
Reber
87
1993
al: Blunt Chest Injuries in 1696
Patients. Eur. J. Cardiothorac.
Surg.1992; 6:284-7.
Reber P, Ris HB, Inderbitzi R, et
al: Osteosynthesis of the Injured
Chest all: Use of the AO
Technique. Scand J Thoracic
Surg. 1993; 27:137-42.
TA
trauma patients with a full range of thoracic injuries over a 20 year
period. Type: Observational_X__Cohort___Prevalence___Case
Control___ Number of Patients: 1696 total Human_X___ or
Animal_____ Results: Overall mortality in total group 5% but 37% in
patients with multiple injuries. Intercostal tube in 638 patients and
thoracotomy in 105 patients. Surgical fixation for flail chest performed
in 29 patients only one in past decade. Mortality of surgical fixation
24% (7/29). In fixation group 9 patients no mechanical ventilation post
op, 11 paitents short course of mechanical ventilation and 2 with
prolonged ventilation. Statistical Methods / Significance: Not done.
Conclusions / Recommendations of Study: Surgical stabilization is the
best policy. Justification grading: Conclusion not supported by study
data. No conclusion from study can be drawn regarding surgical
stabilization in blunt chest patients.
Retrospective study of author’s personal experience with a particular
method of rib fixation in 11 patients. Does not speak to the efficacy
of surgical fixation of flail.
© Copyright 2006 – Eastern Association for the Surgery of Trauma
Ahmed
88
Gyhra
89
Mouton
90
1997
1996
1995
Mouton W, Lardinois D, Furrer M,
et al: Long-term Follow-up of
Patients with Operative
Strabilisaton of a Flail Chest.
Thorac. Cardiovasc. Surgeon.
1997; 45:242-4
Gyhra A, Torres P, Pino J, et al:
Experimental Flail Chest:
Ventilatory Function with Fixation
of Flail Segment in Internal and
External Position. J Trauma.
1996; 40:977-9.
Ahmed Z, Mohyuddin Z:
Management of Flail Chest Injury:
Internal Fixation Versus
Endotracheal Intubation and
Ventilation. J Thorac. Cardiovasc.
Surg. 1995; 110:1676-80.
3
2
3
Prospective controlled animal study of nine cases: In an experimental
model of flail chest , authors compared fixation in internal and
external position. TV, RR and minute volume were significantly
improved by fixation in external position, but were worsened by
fixation in internal position. PaO2 and PaCO2 were not affected.
Therefore changes in mechanics were not secondary to hypoxemia.
Conclusions: rib fixation in external position is preferred. Also, this
work confirms other works indicating that hypoxemia is not induced
by flail per se as hypoxemia was not present and oxygen
administration did not affect respiratory rate. Statistics support
conclusions though study size small.
Design of Study: Case series report over 6 years with flail chest after
trauma and respiratory insufficiency not responding to peridural
analgesia without need for mechanical ventilation for “other” reasons.
Stabilization provided by osteosynthesis of chest wall using AOtechnique with 3.5 mm thick reconstruction plates Type:
Observational_X_Number of Patients: 23 patients Human_X Results:
30 day survival rate 91.4% with deaths secondary to 1 arrhythmia and
1 ARDS/MODS. Mean period to extubation and transfer to the ward
3.9 and 7.8 days respectively. Chest wall appeared symmetrical in all
patients during 28 month mean follow-up. No implant dislocation. 24%
complained of prolonged pain and discomfort more than 3 months
post op. Removal of material in 2 patients resolved chronic pain. 95%
of patients returned to preoperative work capacity and 86% to
preoperative sports activity. Statistical Methods / Significance: Not
done Conclusions / Recommendations of Study: External chest wall
fixation appears attractive in this select subgroup of patients.
Justification grading: Observational study only, no control group, no
Conclusions (implied), are not supported: that patients with flail chest
should have internal rib stabilization (Kirschner wire). Patients not
randomized, no statistical analysis done. Those who had surgical
stabilization had surgery for other reasons, not just stabilization.
Observations ARE interesting though: stabilized patients had fewer
complicatioins, weaned faster, less chest deformities, lower mortality.
© Copyright 2006 – Eastern Association for the Surgery of Trauma
Voggenrei
ter
91
Lardinois
92
1998
2001
Voggenreiter G, Neudeck F,
Aufmkolk M: Operative Chest
Wall Stabilization in Flail Chest –
Outcomes of Patients With or
Without Pulmonary Contusion. J.
Am. Coll. Surg. 1998; 187:130-8
Lardinois D, Krueger T, Dusmet
M, et al: Pulmonary Function
Testing after Operative
Stabilisation of the Chest Wall for
Flail Chest. Eur. J. Cardiothorac.
Surg. 2001; 20:496-501.
3
2
firm conclusions can be drawn.
Retrospective observational study of 42 patients. Results:
1. No significant difference in age, ISS, extent of injury between
groups.
2. In patients with operative stabilization for flail chest without
pulmonary contusion, the ventilator day use was shorter than for
those patients with flail and no contusion without stabilization (6.5 vs.
27 p<0.02) and for flail chest with pulmonary contusion (6.5 vs. 30.8.)
Statistical methods: ANOVA (p<0.02)
Conclusions:
1. Flail chest and respiratory insufficiency without underlying
pulmonary contusion is an indication for chest wall
stabilization.
2. Underlying pulmonary contusion precludes benefit of primary
stabilization. Secondary stabilization may be indicated in the
weaning period.
Justify grading: One group of patients dropped from analysis.
Retrospective in nature, uncontrolled. Did have a hospital set of
criteria. Are the conclusions supported? There may be some validity
in the claims regarding stabilization for insufficiency without
contusion, but this cannot be claimed with major confidence from this
study. .
Prospective, non-randomized observational study of 66 patients with
operative stabilization for flail chest. .
Results: 6 month PFTs revealed VC, FEV1,TLC not indicative of
restriction in all but 5 patients. ( All 5 patents had returned to work.)
Conclusion: the best indication for early operative chest wall
stabilization is antero-lateral flail and respiratory failure without PC.
Secondary stabilization should be considered for PC-FC patients who
have persisting chest wall instability and vent dependence after
healing of contusions.
Justiifcation: Patients had good outcome but non-comparative study.
© Copyright 2006 – Eastern Association for the Surgery of Trauma
Tanaka
87
Mayberry
93
2003
2002
Mayberry JC, Terhes JT, Ellis TJ,
et al: Asbsorbable Plates for Rib
Fracture Repair: Preliminary
Experience. J Trauma. 2003;
55:835-9.
Tanaka H, Yukioka T, Yamaguti
Y, et al: Surgical Stabilization or
Internal Pneumatic Sdtabilization?
A Prospective Randomized Study
of Management of Severe Flail
Chest Patients. J Trauma. 2002;
53:727-32.
1
Jadad
3
3
Design: Randomized controlled study with 37 patients. One group
had rib stabilization, the other managed with internal pneumatic
stabilization. Results: Both groups same based on demographics, and
severity of injury. Ventilator management was the same in both
groups. Incidence of pneumonia at day 21 was 22% in surgical group
and 90% in nonsurgical group. Length of ventilation and Length of
ICU stay was much higher in the nonsurgical group. Tracheostomy
was required in the nonsurgical group in almost all patients and in
only a few of the surgical patients. Total medical expenses in the
nonsurgical group was nearly twice that of the surgical group.
Spirometry showed significantly better %FVC in the surgical group at
one through 12 months. Incidence of chest tightness, thoracic pain
and dyspnea was significantly higher in the nonsurgical group. More
of the surgical group returned to work sooner than the nonsurgical
group. Statistics:Two way analysis of variance with repeated
measures was used to analyze the interactions between groups and
time factors. Tukey's test was used to compare values between the
groups at individual times. Student's t test and chi squared test were
used to compare nonrepeated variables. p<0.05 Conclusions: Judet
strut surgical stabilization may be preferably applied for severe flail
chest patients in whom prolonged ventilatory assistance is expected.
Strengths: Well done. Similar groups to start with. Same ventilator
management with reasonable parameters for intubation and
extubation. Weaknesses: Few numbers. Other: Some might think that
the exclusion of patients with severe brain or spinal cord injury or
perhaps some of the other exclusion criteria introduced bias.
However, the authors were trying to select homogenous groups of
patients with similarly severe chest trauma and to remove other
factors that can affect time on ventilator, etc.
10 patients, non randomized, had fixation of rib fractures with
absorbable plates. Only conclusion: method is safe, was
demonstrated. No statistical analysis; no non-operated cohort; no
objective analysis of results in terms of pain reduction, ICU days,
ventilator days or chest wall stability.
© Copyright 2006 – Eastern Association for the Surgery of Trauma
Balci
94
2004
Balci AE, Eren S, Cakir O, et al:
Open Fixaton in Flail Chest:
Review of 64 Patients. Asian
Cardiovasc. Thorac. Ann. 2004;
12:11-15.
3
RETROSPECTIVE chart review of 64 pts with flail chest. # groups of
pts were identified by the treatments they received: 1.operative
internal fixation of ribs 2. vent support with intermittent PPV or 3 vent
with SIMV. Surgically treated pts did well with lower mort (11% vs 21
and 33% in group 2 and 3),less duration of vent (3d vs 6.6, 7.8d in
groups 2,3). Both groups 2,3 needed pain control beyond epidural
analgesia; group 1 needed only non-narcotic analgesics. ANOVA
used to compare groups.
Conclusion:Operative fixation of flail chest is advantageous
Criticism: Nonrandomized pt allocation…treatment was based on
individual [t indications, thus pts with poor prognosis might not have
been referred for surgery
© Copyright 2006 – Eastern Association for the Surgery of Trauma
1974
1987
1987
3
I
Jadad
4
An
3
Beg MH, Reyazuddin, Ansari MM, 3
Conservative Management of Flail
Chest. J. Indian Med. Assoc.
1990; 88:186-7.
Franz JL, Richardson JD: Effect
of methylprednisolone sodium
succinate on experimental
pulmonary contusion. J Thorac &
CV Surg 1974; 5:842-4
Svennevig JL, Pillgram-Larsen J,
Fjeld NB, et al: Early Use of
Corticosteroids in Severe Closed
Chest Injuries: a 10-year
Experience. Injury. 1987; 18:30912.
Other Therapies (4)
Sinha
1973 Sinha K, dayal A, Charan A:
Towel Clip Tarction: A Simple
95
and Effective Method for the
Treatment of Flail Chest. Indian
J. Chest Diseases. 1973; 15:30711
Franz
96
Svennevig
97
Beg
98
Clinical series of towel clips applied to traumatic flail chest in 23
pts.15/23 pts had good results(symptom free and without any chest
deformity), 6 had fair results (some pain and deformity on D/C). Main
problem was secretion retention due to ineffective cough. No towel
clip site infections or pneumo occurred. No statistical analysis done
Conclusion: External traction by towel clips is effective and safe.
Criticism: Poor study. No controls, no exact measures of ‘good’
results.
Methylprednisolone 30 minutes after experimental pulmonary
contusion in 20 anesthetized dogs.. In steroid treated animals. Weight
ratio between injured and uninjured lung significantly lower. Volume of
injury was less. Results of course not correlated with clinical
outcomes.
Conclusion, that mortality in patients with severe chest injury may be
reduced with use of steroids, is not supported. No randomization, no
criteria used whether or not to give steroids; patients with "severe"
chest injury: only 34% required mechanical ventilation. Cause of
patient mortality not specified, making it impossible to decide whether
or not steroids could have been a factor.
Retrospective series of 100 patients. Results:
1. Multiple injuries are common with 45% intrathoracic and 30%
extrathoracic.
2. Mortality rate is 11%, .average hospital stay is 15 days.
Stats: None except demographic statistics, averages and percents.
Conclusions: Pad and strapping recommended.
Justify grading: Purely observational study. Some treatment options
exercised (e.g. steroid, strapping) would not be considered standard
of care. No conclusions were given in this paper.
© Copyright 2006 – Eastern Association for the Surgery of Trauma